Provider Demographics
NPI:1689661027
Name:GARREN-HUDSON, KIMBERLY ANN (DO)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:ANN
Last Name:GARREN-HUDSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5192 CHILLICOTHE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH RUSSELL
Mailing Address - State:OH
Mailing Address - Zip Code:44022-4196
Mailing Address - Country:US
Mailing Address - Phone:440-338-3366
Mailing Address - Fax:440-338-3332
Practice Address - Street 1:5192 CHILLICOTHE RD
Practice Address - Street 2:
Practice Address - City:SOUTH RUSSELL
Practice Address - State:OH
Practice Address - Zip Code:44022-4196
Practice Address - Country:US
Practice Address - Phone:440-338-3366
Practice Address - Fax:440-338-3332
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3400-7493G207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2328298Medicaid
OHH-63548Medicare UPIN
OH2328298Medicaid