Provider Demographics
NPI:1073388401
Name:KIMBROUGH, DESMOND E I
Entity type:Individual
Prefix:MR
First Name:DESMOND
Middle Name:E
Last Name:KIMBROUGH
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3006 EMBER DR APT 107B
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-1529
Mailing Address - Country:US
Mailing Address - Phone:330-398-9689
Mailing Address - Fax:
Practice Address - Street 1:3006 EMBER DR APT 107B
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30034-1529
Practice Address - Country:US
Practice Address - Phone:330-398-9689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-15
Last Update Date:2023-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program