Provider Demographics
NPI:1972724979
Name:WHITAKER, KIMBERLY B (MD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:B
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1005 HEALTH CENTER DR STE 201
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-4693
Mailing Address - Country:US
Mailing Address - Phone:217-238-6055
Mailing Address - Fax:217-258-2216
Practice Address - Street 1:1100 TUSCOLA BLVD
Practice Address - Street 2:SBL TUSCOLA CLINIC
Practice Address - City:TUSCOLA
Practice Address - State:IL
Practice Address - Zip Code:61953
Practice Address - Country:US
Practice Address - Phone:217-253-2020
Practice Address - Fax:217-253-2023
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AK5901207Q00000X
IL036125554207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036125554Medicaid