Provider Demographics
NPI:1922001767
Name:STOOKE, KIM M (MD)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:M
Last Name:STOOKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 GRAND CENTRAL MALL
Mailing Address - Street 2:SUITE 4
Mailing Address - City:VIENNA
Mailing Address - State:WV
Mailing Address - Zip Code:26105-4131
Mailing Address - Country:US
Mailing Address - Phone:304-485-3300
Mailing Address - Fax:304-485-3317
Practice Address - Street 1:800 GRAND CENTRAL MALL
Practice Address - Street 2:SUITE 4
Practice Address - City:VIENNA
Practice Address - State:WV
Practice Address - Zip Code:26105-4131
Practice Address - Country:US
Practice Address - Phone:304-485-3300
Practice Address - Fax:304-485-3317
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35.088838207Q00000X
WV18455207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0046995000Medicaid
OH2045405Medicaid
WV0046995000Medicaid
WVG22091Medicare UPIN
OH2045405Medicaid