Provider Demographics
NPI:1306959432
Name:TYNER, KIMBERLY S (MD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:S
Last Name:TYNER
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:PO BOX 871
Mailing Address - Street 2:
Mailing Address - City:TERRELL
Mailing Address - State:TX
Mailing Address - Zip Code:75160-0017
Mailing Address - Country:US
Mailing Address - Phone:972-722-5959
Mailing Address - Fax:972-722-5538
Practice Address - Street 1:2504 RIDGE RD
Practice Address - Street 2:SUITE 201
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75087-2569
Practice Address - Country:US
Practice Address - Phone:972-722-5959
Practice Address - Fax:972-722-5538
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL5594207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX160462101Medicaid
NV100512421Medicaid
TX00864TOtherMEDICARE GROUP PTAN
TX160462102Medicaid
TXTXB113141Medicare PIN
NV100512421Medicaid
TX00864TOtherMEDICARE GROUP PTAN