Provider Demographics
NPI:1457365314
Name:PEZZONI, KIMBER L (MD)
Entity Type:Individual
Prefix:DR
First Name:KIMBER
Middle Name:L
Last Name:PEZZONI
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 1:9450 SW BARNES RD STE 200
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-6638
Mailing Address - Country:US
Mailing Address - Phone:503-216-2025
Mailing Address - Fax:503-216-5529
Practice Address - Street 1:9450 SW BARNES RD STE 200
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6638
Practice Address - Country:US
Practice Address - Phone:503-216-2025
Practice Address - Fax:503-216-5529
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-PHYS-LIC-357482084P0800X, 2084P0804X
ORMD264182084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
139974Medicare PIN