Provider Demographics
NPI:1194773598
Name:TANABE, KIMBERLY R (MD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:R
Last Name:TANABE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-706-8000
Mailing Address - Fax:208-706-8001
Practice Address - Street 1:3101 E STATE ST
Practice Address - Street 2:SUITE 2120
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6232
Practice Address - Country:US
Practice Address - Phone:208-473-3275
Practice Address - Fax:208-473-3276
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDM5831207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20000418Medicare PIN