Provider Demographics
NPI:1629293493
Name:LOVELACE, KIMBERLEY R (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:R
Last Name:LOVELACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KIMBERLEY
Other - Middle Name:R
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3524 E MILWAUKEE ST
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53546-1626
Mailing Address - Country:US
Mailing Address - Phone:608-756-7110
Mailing Address - Fax:608-756-7106
Practice Address - Street 1:3524 E MILWAUKEE ST
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53546-1626
Practice Address - Country:US
Practice Address - Phone:608-756-7110
Practice Address - Fax:608-756-7106
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN# 390200000X207W00000X
CODR.51421207W00000X
WI50588-20207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO78572223Medicaid
COCOA108593Medicare PIN