Provider Demographics
NPI:1457359192
Name:PHILLIPS, KIMBERLY ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:ANN
Last Name:PHILLIPS
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 1:1312 E LUMSDEN RD STE 304
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-6717
Mailing Address - Country:US
Mailing Address - Phone:813-409-3998
Mailing Address - Fax:800-379-8041
Practice Address - Street 1:1312 E LUMSDEN RD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-6717
Practice Address - Country:US
Practice Address - Phone:813-409-3998
Practice Address - Fax:800-379-8041
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT036960207Q00000X
FLME142657208M00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004215944Medicaid
CTG82066Medicare UPIN