Provider Demographics
NPI:1821042060
Name:SUPPES, KIMBERLY C (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:C
Last Name:SUPPES
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 1:595 MARTHA JEFFERSON DR STE 320
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22911-4669
Mailing Address - Country:US
Mailing Address - Phone:434-654-8715
Mailing Address - Fax:
Practice Address - Street 1:595 MARTHA JEFFERSON DR STE 320
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22911-4669
Practice Address - Country:US
Practice Address - Phone:434-654-8715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001018694208600000X
VA0101276400208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
G01681Medicare UPIN
MO002013776Medicare PIN
MO991337002Medicare PIN
MOP00960195Medicare PIN
MOMA3716006Medicare PIN
MO968235236Medicare PIN