Provider Demographics
NPI:1265428924
Name:KIMBALL, GLENN P JR (MD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:P
Last Name:KIMBALL
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:680 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HAVERHILL
Mailing Address - State:MA
Mailing Address - Zip Code:01830-2644
Mailing Address - Country:US
Mailing Address - Phone:978-374-4258
Mailing Address - Fax:978-374-4982
Practice Address - Street 1:680 MAIN ST
Practice Address - Street 2:
Practice Address - City:HAVERHILL
Practice Address - State:MA
Practice Address - Zip Code:01830-2644
Practice Address - Country:US
Practice Address - Phone:978-374-4258
Practice Address - Fax:978-374-4982
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA57624207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3035913Medicaid
MA3035913Medicaid
MAGLM20934Medicare ID - Type UnspecifiedMEDICARE