Provider Demographics
NPI:1679531958
Name:LAMACK, KIMBERLY A (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:LAMACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 N MAYFAIR ROAD
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4216
Mailing Address - Country:US
Mailing Address - Phone:414-771-8228
Mailing Address - Fax:414-256-2483
Practice Address - Street 1:201 N MAYFAIR ROAD
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-4216
Practice Address - Country:US
Practice Address - Phone:414-771-8228
Practice Address - Fax:414-256-2483
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN102571207RE0101X
MN49002207RE0101X
WI48723207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN590060000Medicaid
WI35320400Medicaid
MNP00388222OtherRAILROAD MEDICARE
IAENROLLEDMedicaid
IAENROLLEDMedicaid
MN460000286Medicare PIN