Provider Demographics
NPI:1801830070
Name:FREEMAN, KIMBERLY DIANE (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DIANE
Last Name:FREEMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4989
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-1989
Mailing Address - Country:US
Mailing Address - Phone:209-213-9192
Mailing Address - Fax:
Practice Address - Street 1:18144 SECO ST
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:CA
Practice Address - Zip Code:95327-9498
Practice Address - Country:US
Practice Address - Phone:209-984-4820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2021-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA81141207P00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI15990Medicare UPIN