Provider Demographics
NPI:1386084259
Name:KIMBELL, JOSEPH CARR (DO)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:CARR
Last Name:KIMBELL
Suffix:
Gender:M
Credentials:DO
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 78866
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53278-8866
Mailing Address - Country:US
Mailing Address - Phone:779-696-1750
Mailing Address - Fax:
Practice Address - Street 1:230 W. BLACKHAWK BLVD.
Practice Address - Street 2:
Practice Address - City:BYRON
Practice Address - State:IL
Practice Address - Zip Code:61010
Practice Address - Country:US
Practice Address - Phone:779-696-1300
Practice Address - Fax:815-234-2314
Is Sole Proprietor?:No
Enumeration Date:2013-06-25
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101020749208800000X
IL036141869207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208800000XAllopathic & Osteopathic PhysiciansUrology