Provider Demographics
NPI:1750366704
Name:KIMBROUGH, ELIZABETH L (MD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:L
Last Name:KIMBROUGH
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 1:3232 N BALLARD RD
Mailing Address - Street 2:APPLETON
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-8804
Mailing Address - Country:US
Mailing Address - Phone:920-749-9668
Mailing Address - Fax:920-734-5307
Practice Address - Street 1:491 S WASHBURN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-6733
Practice Address - Country:US
Practice Address - Phone:920-292-5555
Practice Address - Fax:920-292-1717
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI42248207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI13124OtherDEAN
WIWI01A2OtherJOHN DEERE
WI110232655OtherRAILROAD MEDICARE
WI390807236YYOtherUNITY
WI33345700Medicaid
WI390807236YYOtherUNITY
WI33345700Medicaid