Provider Demographics
NPI:1871153106
Name:FARIAS, KIMBERLY (DO)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:FARIAS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12608 SOUTH FWY STE 140
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-8435
Mailing Address - Country:US
Mailing Address - Phone:817-295-7214
Mailing Address - Fax:817-295-7062
Practice Address - Street 1:12608 SOUTH FWY STE 140
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-8435
Practice Address - Country:US
Practice Address - Phone:817-295-7214
Practice Address - Fax:817-295-7062
Is Sole Proprietor?:No
Enumeration Date:2019-06-18
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXT4743207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program