Provider Demographics
NPI:1396876264
Name:KIMURA, MARILYN H (MD)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:H
Last Name:KIMURA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 CEDAR ST # 237
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-1410
Mailing Address - Country:US
Mailing Address - Phone:208-904-2702
Mailing Address - Fax:208-904-2703
Practice Address - Street 1:303 E VANDERBILT WAY
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92415-0026
Practice Address - Country:US
Practice Address - Phone:909-388-0810
Practice Address - Fax:909-890-0281
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM110812084P0800X
CAG754402084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry