Provider Demographics
NPI:1174609556
Name:KIMBALL, MATTHEW MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:MICHAEL
Last Name:KIMBALL
Suffix:
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 1:10470 OLD PLACERVILLE RD
Mailing Address - Street 2:#100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:866-681-0736
Mailing Address - Fax:
Practice Address - Street 1:2 MEDICAL PLAZA DR
Practice Address - Street 2:#205
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3043
Practice Address - Country:US
Practice Address - Phone:916-773-8711
Practice Address - Fax:916-773-8712
Is Sole Proprietor?:No
Enumeration Date:2006-10-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME103822207T00000X
FLTRN10275207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007180500Medicaid
FLME103822OtherFLORIDA LICENSE
FLAD9470826-510487OtherDEA#
FLFK1838145OtherFLORIDA DEA
FLME103822OtherFLORIDA LICENSE
FL28207XMedicare PIN