Provider Demographics
NPI:1265428254
Name:KIMBALL, BRIAN D (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:D
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 1:1000 AINSWORTH DR
Mailing Address - Street 2:SUITE 115
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-1667
Mailing Address - Country:US
Mailing Address - Phone:928-778-1971
Mailing Address - Fax:928-443-8473
Practice Address - Street 1:1000 AINSWORTH DR
Practice Address - Street 2:SUITE 115
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-1667
Practice Address - Country:US
Practice Address - Phone:928-778-1971
Practice Address - Fax:928-443-8473
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2011-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ23681174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ333568Medicaid
G21191Medicare UPIN
AZ333568Medicaid
Z76088Medicare PIN