Provider Demographics
NPI:1386611150
Name:DEROCHE, KIMBERLY KNOWLES (MD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:KNOWLES
Last Name:DEROCHE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ANN
Other - Last Name:KNOWLES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2849 JOHNSON ST NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55418-3055
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2849 JOHNSON ST NE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55418-3055
Practice Address - Country:US
Practice Address - Phone:612-706-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN41601207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNG95276Medicare UPIN