Provider Demographics
NPI:1992782098
Name:WATERFALL, KIM W (MD)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:W
Last Name:WATERFALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5571 CHOWNING WAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-1479
Mailing Address - Country:US
Mailing Address - Phone:614-625-6621
Mailing Address - Fax:
Practice Address - Street 1:5571 CHOWNING WAY
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-1479
Practice Address - Country:US
Practice Address - Phone:614-625-6621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-29
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH090079207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000111941OtherANTHEM
00000499190 04OtherUNITED HEALTHCARE
IN200115550Medicaid
IN7336OtherPHYSICIANS HAELTH PLAN
IN3937240020OtherMEDICARE DMEPOS
5736320OtherAETNA
5736320OtherAETNA
B44209Medicare UPIN
IN138160FMedicare ID - Type Unspecified