Provider Demographics
NPI:1457561706
Name:KIMBROUGH, MARY K (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:KIMBROUGH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:KATHERINE
Other - Last Name:WHITLOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4301 W MARKHAM ST # 783
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-7101
Mailing Address - Country:US
Mailing Address - Phone:501-686-8000
Mailing Address - Fax:501-526-5148
Practice Address - Street 1:4301 W MARKHAM ST # 520
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-7101
Practice Address - Country:US
Practice Address - Phone:501-686-6648
Practice Address - Fax:501-686-7280
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2023302086S0127X
ARE-82112086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1214906Medicaid
LA4P712F600OtherMEDICARE - PTAN