Provider Demographics
NPI:1245387091
Name:EMERSON, KIMBERLY JOY (MD)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:JOY
Last Name:EMERSON
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:PO BOX 188
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:AR
Mailing Address - Zip Code:72745-0188
Mailing Address - Country:US
Mailing Address - Phone:479-464-8111
Mailing Address - Fax:479-464-4475
Practice Address - Street 1:903 SE 28TH ST
Practice Address - Street 2:SUITE 1
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-3880
Practice Address - Country:US
Practice Address - Phone:479-464-8111
Practice Address - Fax:479-464-4475
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE2176207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR136993001Medicaid
AR5L238Medicare ID - Type UnspecifiedMEDICARE AR BCBS