Provider Demographics
NPI:1356382949
Name:KIMBALL, FREDERICK J (MD)
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:J
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 1:4301 HOYT AVE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98203-2316
Mailing Address - Country:US
Mailing Address - Phone:425-317-8025
Mailing Address - Fax:
Practice Address - Street 1:4301 HOYT AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203-2316
Practice Address - Country:US
Practice Address - Phone:425-317-8025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00018773207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1758507Medicaid
WA0155673OtherLABOR AND INDUSTRY
WAMD00018773OtherSTATE LICENSE NUMBER
A09135Medicare UPIN
WAAB27170Medicare PIN