Provider Demographics
NPI:1922044239
Name:KIMMEL, DOUGLAS J (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:J
Last Name:KIMMEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 2ND AVE SW
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:SD
Mailing Address - Zip Code:57401-4115
Mailing Address - Country:US
Mailing Address - Phone:605-725-2560
Mailing Address - Fax:605-725-8782
Practice Address - Street 1:305 S STATE ST
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-4527
Practice Address - Country:US
Practice Address - Phone:605-622-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD39402085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND21258OtherBCBS
ND18453Medicaid
SD7201012Medicaid
SD0008378OtherBCBS
MN099816800Medicaid
SDS8378Medicare PIN
SD300124605Medicare ID - Type UnspecifiedRAILROAD
SD7201012Medicaid