Provider Demographics
NPI:1205917374
Name:KIMBALL, JON POTTER (MD)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:POTTER
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 1:1988 GULF TO BAY BLVD
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33765-3550
Mailing Address - Country:US
Mailing Address - Phone:727-953-8090
Mailing Address - Fax:727-953-8088
Practice Address - Street 1:1988 GULF TO BAY BLVD
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33765-3550
Practice Address - Country:US
Practice Address - Phone:727-953-8090
Practice Address - Fax:727-953-8088
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2013-00103207X00000X
FLME96185207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL17EIVOtherBCBS
NC177VXOtherBCBSNC PROVIDER ID NUMBER
FL856543OtherCIGNA