Provider Demographics
NPI:1740335017
Name:KIMMEL, RICHARD D (DO)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:D
Last Name:KIMMEL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 CLINT MOORE RD
Mailing Address - Street 2:SUITE 215
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33496-2658
Mailing Address - Country:US
Mailing Address - Phone:561-477-0210
Mailing Address - Fax:561-470-0198
Practice Address - Street 1:1905 CLINT MOORE RD
Practice Address - Street 2:SUITE 215
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33496-2658
Practice Address - Country:US
Practice Address - Phone:561-477-0210
Practice Address - Fax:561-470-0198
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS 6191208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL057435000Medicaid
FL80534Medicare ID - Type Unspecified
FL057435000Medicaid