1174510127 NPI number — DR. KIMBERLY ROSE GATZIMOS MD

Table of content: DR. KIMBERLY ROSE GATZIMOS MD (NPI 1174510127)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174510127 NPI number — DR. KIMBERLY ROSE GATZIMOS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GATZIMOS
Provider First Name:
KIMBERLY
Provider Middle Name:
ROSE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JOHNSON
Provider Other First Name:
KIMBERLY
Provider Other Middle Name:
ROSE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1174510127
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/19/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6101 BLUE LAGOON DR STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33126-3168
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
844-630-0700
Provider Business Mailing Address Fax Number:
877-374-1924

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5430 E WASHINGTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46219-6446
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-969-7935
Provider Business Practice Location Address Fax Number:
877-550-2158
Provider Enumeration Date:
10/04/2005

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: 207R00000X , with the licence number:  01037050 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200134930 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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