Provider Demographics
NPI:1902016553
Name:KIMERLING, MICHAEL C
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:C
Last Name:KIMERLING
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3887 SEDGWICK AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-4466
Mailing Address - Country:US
Mailing Address - Phone:718-548-7295
Mailing Address - Fax:718-548-7174
Practice Address - Street 1:3887 SEDGWICK AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-4401
Practice Address - Country:US
Practice Address - Phone:718-548-7295
Practice Address - Fax:718-548-7174
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004171-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician