Provider Demographics
NPI:1841561198
Name:DEREZIL, KIMBERLY (MD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:
Last Name:DEREZIL
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 1:1401 EASTON AVE
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18018-2618
Mailing Address - Country:US
Mailing Address - Phone:484-893-1482
Mailing Address - Fax:610-625-2311
Practice Address - Street 1:1401 EASTON AVE
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18018-2618
Practice Address - Country:US
Practice Address - Phone:862-755-9075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-18
Last Update Date:2022-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAMD452662207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA311498Medicare PIN
PA213827Medicare PIN