1245309996 NPI number — MRS. KIMBERLY ANN DOPPELT (CHANGED FROM KELLER) PA-C

Table of content: MRS. KIMBERLY ANN DOPPELT (CHANGED FROM KELLER) PA-C (NPI 1245309996)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245309996 NPI number — MRS. KIMBERLY ANN DOPPELT (CHANGED FROM KELLER) PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOPPELT (CHANGED FROM KELLER)
Provider First Name:
KIMBERLY
Provider Middle Name:
ANN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245309996
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/23/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
901 LAKESHORE DR.
Provider Second Line Business Mailing Address:
#108
Provider Business Mailing Address City Name:
ISHPEMING
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49849
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
906-485-2747
Provider Business Mailing Address Fax Number:
906-485-2732

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5530 WISCONSIN AVE
Provider Second Line Business Practice Location Address:
SUITE 1660
Provider Business Practice Location Address City Name:
CHEVY CHASE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20815-4404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-657-9876
Provider Business Practice Location Address Fax Number:
301-657-8240
Provider Enumeration Date:
11/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AS0400X , with the licence number:  C0003421 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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