Provider Demographics
NPI:1992081392
Name:DEERY, KIMBERLY JEANNE (DO)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JEANNE
Last Name:DEERY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:JEANNE
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:63 N LAKEVIEW DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:GIBBSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08026-1026
Mailing Address - Country:US
Mailing Address - Phone:856-435-6000
Mailing Address - Fax:856-782-1667
Practice Address - Street 1:63 N LAKEVIEW DR
Practice Address - Street 2:SUITE 202
Practice Address - City:GIBBSBORO
Practice Address - State:NJ
Practice Address - Zip Code:08026-1026
Practice Address - Country:US
Practice Address - Phone:856-435-6000
Practice Address - Fax:856-782-1667
Is Sole Proprietor?:No
Enumeration Date:2011-10-30
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB09678700208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100749410OtherOKLAHOMA HEALTH CARE AUTHORITY