Provider Demographics
NPI:1194770198
Name:KIMURA, IBUKI A (MD)
Entity type:Individual
Prefix:
First Name:IBUKI
Middle Name:A
Last Name:KIMURA
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 1:700 S PARK ST
Mailing Address - Street 2:ST MARYS HOSPITAL DEAN MEDICAL CENTER
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1849
Mailing Address - Country:US
Mailing Address - Phone:608-251-6100
Mailing Address - Fax:
Practice Address - Street 1:700 S PARK ST
Practice Address - Street 2:ST MARYS HOSPITAL DEAN MEDICAL CENTER
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1849
Practice Address - Country:US
Practice Address - Phone:608-251-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI39081-020207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1194770198Medicaid
WI60360OtherDEAN HEALTH INSURANCE
WIP00224730Medicare PIN
H01395Medicare UPIN
WI091674150Medicare PIN