Provider Demographics
NPI:1922533553
Name:KIMBALL, EBEN JOSHUA (MD)
Entity Type:Individual
Prefix:
First Name:EBEN
Middle Name:JOSHUA
Last Name:KIMBALL
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 1:20 SCOFIELD HILL RD
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON DEPOT
Mailing Address - State:CT
Mailing Address - Zip Code:06794-1012
Mailing Address - Country:US
Mailing Address - Phone:860-671-0797
Mailing Address - Fax:
Practice Address - Street 1:8268 164TH ST
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-1104
Practice Address - Country:US
Practice Address - Phone:718-883-4590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-20
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY306948207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program