Provider Demographics
NPI:1700220936
Name:ELLIS, KIMBERLY KONE (MD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:KONE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3939 MEDICAL DR STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-2292
Mailing Address - Country:US
Mailing Address - Phone:210-450-6120
Mailing Address - Fax:210-450-6162
Practice Address - Street 1:3939 MEDICAL DR
Practice Address - Street 2:STE 100
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-2291
Practice Address - Country:US
Practice Address - Phone:210-450-6120
Practice Address - Fax:210-450-6161
Is Sole Proprietor?:No
Enumeration Date:2013-04-18
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ9179207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX362107002OtherCSHCN
TX362107001Medicaid
TX362107002OtherCSHCN