Provider Demographics
NPI:1306038997
Name:BLEWETT, KIMBERLEY D (DO)
Entity type:Individual
Prefix:DR
First Name:KIMBERLEY
Middle Name:D
Last Name:BLEWETT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KIMBERLEY
Other - Middle Name:DAWN
Other - Last Name:CATTRON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:623 SOUTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843
Mailing Address - Country:US
Mailing Address - Phone:208-882-2011
Mailing Address - Fax:208-883-1853
Practice Address - Street 1:623 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843
Practice Address - Country:US
Practice Address - Phone:208-882-2011
Practice Address - Fax:208-883-1853
Is Sole Proprietor?:No
Enumeration Date:2007-08-16
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT66740581204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000061344Medicare PIN
000063074Medicare PIN
000061345Medicare PIN
000061346Medicare PIN
000061343Medicare PIN