Provider Demographics
NPI:1871593244
Name:PANZARELLA, KIM MARIE (MD)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:MARIE
Last Name:PANZARELLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:201 CONCOURSE BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059-5640
Mailing Address - Country:US
Mailing Address - Phone:804-549-4030
Mailing Address - Fax:804-549-4032
Practice Address - Street 1:320A CHARLES H DIMMOCK PKWY
Practice Address - Street 2:
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-2917
Practice Address - Country:US
Practice Address - Phone:804-526-7364
Practice Address - Fax:804-526-7394
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2019-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101231763207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
2906423OtherAETNA
070016578OtherRAILROAD MEDICARE
VA005902096Medicaid
0300462OtherUNITED HEALTHCARE
150946OtherSOUTHERN HEALTH
384358OtherANTHEM
384358OtherANTHEM
VA070000347Medicare ID - Type Unspecified