Provider Demographics
NPI:1891327094
Name:KIMBROUGH, MARILYN ELAINE (MD)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:ELAINE
Last Name:KIMBROUGH
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 1:34800 BOB WILSON DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-1098
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:34800 BOB WILSON DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-1098
Practice Address - Country:US
Practice Address - Phone:619-881-9159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-06
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X
VA101272614171000000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No171000000XOther Service ProvidersMilitary Health Care Provider