Healthcare Provider Details

I. General information

NPI: 1770675738
Provider Name (Legal Business Name): KIMBERLY MARIE DOUGLAS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIMBERLY MARIE CORRAL M.D.

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 07/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

436 5TH & TED STEVENS WAY
KOTZEBUE AK
99752-0043
US

IV. Provider business mailing address

PO BOX 43
KOTZEBUE AK
99752-0043
US

V. Phone/Fax

Practice location:
  • Phone: 907-442-3321
  • Fax: 907-442-7250
Mailing address:
  • Phone: 907-223-4365
  • Fax: 907-442-7306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number6568
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: