Provider Demographics
NPI:1013103191
Name:KIMBERLY UDELL D.O., P.A.
Entity Type:Organization
Organization Name:KIMBERLY UDELL D.O., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:UDELL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:817-468-1506
Mailing Address - Street 1:3602 MATLOCK RD STE 206
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76015-3600
Mailing Address - Country:US
Mailing Address - Phone:817-468-1506
Mailing Address - Fax:817-468-1520
Practice Address - Street 1:3602 MATLOCK RD STE 206
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76015-3600
Practice Address - Country:US
Practice Address - Phone:817-468-1506
Practice Address - Fax:817-468-1520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-21
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1225174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX165666201Medicaid
TX8P5630OtherBLUE CROSS BLUE SHIELD