Provider Demographics
NPI:1699838755
Name:WILLIS COATES, KIMBERLY (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:WILLIS COATES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:W
Other - Last Name:COATES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:511 OAKWOOD BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78681-4007
Mailing Address - Country:US
Mailing Address - Phone:512-255-0769
Mailing Address - Fax:512-255-4569
Practice Address - Street 1:511 OAKWOOD BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681-4007
Practice Address - Country:US
Practice Address - Phone:512-255-0769
Practice Address - Fax:512-255-4569
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ1937207VG0400X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0064LPOtherBCBS INDIVIDUAL
TXJ1937OtherSTATE LICENSE NUMBER
TX20-0972212OtherTAX ID
TX8C0284Medicare PIN
TX00924WMedicare PIN
TXG26181Medicare UPIN