Provider Demographics
NPI:1750344966
Name:EAKIN WEGENER, KIMBERLY (MD)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:
Last Name:EAKIN WEGENER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:EAKIN
Other - Last Name:WEGENER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:
Practice Address - Street 1:8288 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-5262
Practice Address - Country:US
Practice Address - Phone:903-593-1721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK0459207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0408205-01Medicaid
TX110211298OtherRR/MEDICARE
TX040820502Medicaid
TX752616977118OtherTRICARE
TX88485QOtherBCBS
TXP00650860Medicare PIN
TX0408205-01Medicaid
TX040820502Medicaid