Provider Demographics
NPI:1720191638
Name:ZIPPER, KIM ENTWISTLE (MD)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:ENTWISTLE
Last Name:ZIPPER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KIM
Other - Middle Name:MARGUERITE
Other - Last Name:ENTWISTLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1304 OAK ST
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3111
Mailing Address - Country:US
Mailing Address - Phone:321-723-4723
Mailing Address - Fax:321-727-1448
Practice Address - Street 1:1304 OAK ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3111
Practice Address - Country:US
Practice Address - Phone:321-723-4723
Practice Address - Fax:321-727-1448
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME67801207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL31739OtherBCBSFL
FLG27906Medicare UPIN
FL31739OtherBCBSFL