Provider Demographics
NPI:1447356522
Name:KIMMEL, MARK (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:KIMMEL
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 1:536 SAYBROOK RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-4712
Mailing Address - Country:US
Mailing Address - Phone:860-358-2220
Mailing Address - Fax:860-358-2222
Practice Address - Street 1:536 SAYBROOK RD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-4712
Practice Address - Country:US
Practice Address - Phone:860-358-2220
Practice Address - Fax:860-358-2222
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT031390207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
36503OtherCHAMPUS
533929OtherAETNA
CT031390OtherCONNECTICARE
CT010031390CT03OtherBLUECARE FAMILY PLAN
CT0V1840OtherHEALTHNET
P399969OtherOXFORD
CT1313907Medicaid
CT010031390CT03OtherANTHEM
0131390OtherUNITED HEALTHCARE
CT830001803OtherRAILROAD MEDICARE
P399969OtherOXFORD
CT440000044Medicare ID - Type Unspecified