Provider Demographics
NPI:1720061385
Name:WALLMAN, KIMBERLY KAY (DO)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:KAY
Last Name:WALLMAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:POGLESE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:325 E H ST
Mailing Address - Street 2:
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-4760
Mailing Address - Country:US
Mailing Address - Phone:906-774-3300
Mailing Address - Fax:
Practice Address - Street 1:1414 W FAIR AVE STE 285
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-5406
Practice Address - Country:US
Practice Address - Phone:906-226-4618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010149572084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4785309Medicaid
MIP00260303OtherRAILROAD MEDICARE
MIP00260303OtherRAILROAD MEDICARE