Provider Demographics
NPI:1770675738
Name:DOUGLAS, KIMBERLY MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:MARIE
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KIMBERLY
Other - Middle Name:MARIE
Other - Last Name:CORRAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 43
Mailing Address - Street 2:
Mailing Address - City:KOTZEBUE
Mailing Address - State:AK
Mailing Address - Zip Code:99752-0043
Mailing Address - Country:US
Mailing Address - Phone:907-223-4365
Mailing Address - Fax:907-442-7306
Practice Address - Street 1:436 5TH & TED STEVENS WAY
Practice Address - Street 2:
Practice Address - City:KOTZEBUE
Practice Address - State:AK
Practice Address - Zip Code:99752-0043
Practice Address - Country:US
Practice Address - Phone:907-442-3321
Practice Address - Fax:907-442-7250
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK6568207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKHS19IPMedicaid
AKHS19OPMedicaid
AKTEZ042Medicare PIN
AK021310Medicare Oscar/Certification