Provider Demographics
NPI:1912155706
Name:KIMMEL, ROBERT R JR (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:R
Last Name:KIMMEL
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1029 E MAIN STE 104
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-3814
Mailing Address - Country:US
Mailing Address - Phone:253-446-6977
Mailing Address - Fax:253-604-4703
Practice Address - Street 1:1029 E MAIN STE 104
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3814
Practice Address - Country:US
Practice Address - Phone:253-446-6977
Practice Address - Fax:253-604-4703
Is Sole Proprietor?:No
Enumeration Date:2008-09-04
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO36385207RE0101X
WAMD00020915207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8562209Medicaid
MO36385OtherMISSOURI LICENSE
WA8562209Medicaid