Provider Demographics
NPI:1053540724
Name:KIMBALL, PAUL ALLEN (OD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:ALLEN
Last Name:KIMBALL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 N SAGINAW RD
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-3350
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:217 N SAGINAW RD
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-3350
Practice Address - Country:US
Practice Address - Phone:989-631-2653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-02
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004555152W00000X
VA0618001848152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2803002Medicare PIN