Provider Demographics
NPI:1124169453
Name:KIMBALL, SEAN L (DO)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:L
Last Name:KIMBALL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:434 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:12866-8627
Mailing Address - Country:US
Mailing Address - Phone:518-769-2893
Mailing Address - Fax:518-207-4487
Practice Address - Street 1:434 CHURCH ST
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:12866-8627
Practice Address - Country:US
Practice Address - Phone:518-769-2893
Practice Address - Fax:518-207-4487
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY249528207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03028888Medicaid
NYP00642757OtherRR MEDICARE
NYP00642757OtherRR MEDICARE