Provider Demographics
NPI:1891780631
Name:KIMMEL, DOUGLAS (DO)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:KIMMEL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1648 HUNTINGDON PIKE
Mailing Address - Street 2:MEDICAL STAFF OFFICE 1ST FLR
Mailing Address - City:MEADOWBROOK
Mailing Address - State:PA
Mailing Address - Zip Code:19046-8001
Mailing Address - Country:US
Mailing Address - Phone:215-938-3450
Mailing Address - Fax:215-938-3829
Practice Address - Street 1:23 BUSTLETON PIKE
Practice Address - Street 2:SUITE 100
Practice Address - City:FEASTERVILLE TREVOSE
Practice Address - State:PA
Practice Address - Zip Code:19053-6446
Practice Address - Country:US
Practice Address - Phone:215-464-9599
Practice Address - Fax:215-464-7865
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS006506L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA570038OtherPA BLUE SHIELD
PA01767OS006506LMedicaid
PA0391404000OtherKEYSTONE HEALTH PLAN EAST
PA98765OtherAETNA US HEATLHCARE
PA100416CMedicaid
PA570038OtherPA BLUE SHIELD
PA100416CMedicaid