Provider Demographics
NPI:1679035380
Name:KIMBLE, MARRELL JAVAR (MD)
Entity Type:Individual
Prefix:
First Name:MARRELL
Middle Name:JAVAR
Last Name:KIMBLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13670 WALSINGHAM RD
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33774-3532
Mailing Address - Country:US
Mailing Address - Phone:727-593-9848
Mailing Address - Fax:727-596-4532
Practice Address - Street 1:13670 WALSINGHAM RD
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33774-3532
Practice Address - Country:US
Practice Address - Phone:727-593-9848
Practice Address - Fax:727-596-4532
Is Sole Proprietor?:No
Enumeration Date:2019-04-02
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME149976207Q00000X
FL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program