Provider Demographics
NPI:1366448359
Name:KIMURA, IRENE KIMIVO (MD)
Entity type:Individual
Prefix:DR
First Name:IRENE
Middle Name:KIMIVO
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 1:821 E BROADWAY AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-5934
Mailing Address - Country:US
Mailing Address - Phone:509-765-1602
Mailing Address - Fax:509-766-9778
Practice Address - Street 1:821 E BROADWAY AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-5934
Practice Address - Country:US
Practice Address - Phone:509-765-1602
Practice Address - Fax:509-766-9778
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00032544207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8178360Medicaid
WAG11495Medicare UPIN
WAAB34361Medicare ID - Type UnspecifiedMEDICARE