Provider Demographics
NPI:1770682379
Name:LEDERMAN, KIMBERLY WALL (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:WALL
Last Name:LEDERMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KIMBERLY
Other - Middle Name:ANNE
Other - Last Name:WALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6453 CECIL AVE
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:MO
Mailing Address - Zip Code:63105-2224
Mailing Address - Country:US
Mailing Address - Phone:314-725-7787
Mailing Address - Fax:
Practice Address - Street 1:6420 CLAYTON RD
Practice Address - Street 2:
Practice Address - City:RICHMOND HEIGHTS
Practice Address - State:MO
Practice Address - Zip Code:63117-1811
Practice Address - Country:US
Practice Address - Phone:314-768-8360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO114588207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203801717Medicaid
MOG77550Medicare UPIN
MO965915198Medicare PIN