Provider Demographics
NPI:1972568913
Name:DELTUVA, KIMBERLY ANN JOHNSTON (MD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN JOHNSTON
Last Name:DELTUVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:A
Other - Last Name:JOHNSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:41 MAGNA WAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21157-3008
Mailing Address - Country:US
Mailing Address - Phone:410-751-6684
Mailing Address - Fax:410-751-2371
Practice Address - Street 1:41 MAGNA WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157-3008
Practice Address - Country:US
Practice Address - Phone:410-751-6684
Practice Address - Fax:410-751-2371
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0055498207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD110205200Medicaid
MD472717ZS3LMedicare PIN
H18061Medicare UPIN