Provider Demographics
NPI:1063737963
Name:KIMBLE, DERRICK E (MED)
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:E
Last Name:KIMBLE
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2903 GALAHAD WAY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-9147
Mailing Address - Country:US
Mailing Address - Phone:706-495-2351
Mailing Address - Fax:
Practice Address - Street 1:2903 GALAHAD WAY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-9147
Practice Address - Country:US
Practice Address - Phone:706-495-2351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-02
Last Update Date:2010-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional