Provider Demographics
NPI:1720064652
Name:ADDIS, KIMBERLY A (MD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:A
Last Name:ADDIS
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 1:4777 US HIGHWAY 259
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-7668
Mailing Address - Country:US
Mailing Address - Phone:903-663-7393
Mailing Address - Fax:903-663-7394
Practice Address - Street 1:4777 US HIGHWAY 259
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-7668
Practice Address - Country:US
Practice Address - Phone:903-663-7393
Practice Address - Fax:903-663-7394
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.00500652085R0202X
TXM14662085R0202X
TXM14462085R0204X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX176592701Medicaid
I40862Medicare UPIN
TX8D9055Medicare ID - Type Unspecified