Provider Demographics
NPI:1063619518
Name:STUMP, KIMBERLY SUSAN (MD)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:SUSAN
Last Name:STUMP
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5536 SALAL ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97306-2184
Mailing Address - Country:US
Mailing Address - Phone:214-418-3699
Mailing Address - Fax:
Practice Address - Street 1:900 STATE ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3922
Practice Address - Country:US
Practice Address - Phone:503-370-6062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-28
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP1496207Q00000X
NHRT1676390200000X
ORMD194544207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program