Healthcare Provider Details

I. General information

NPI: 1588648653
Provider Name (Legal Business Name): MICHAEL PATTON KIMBALL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2005
Last Update Date: 12/23/2024
Certification Date: 12/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9333 GENESEE AVE STE 350
SAN DIEGO CA
92121-2103
US

IV. Provider business mailing address

9333 GENESEE AVE STE 350
SAN DIEGO CA
92121-2103
US

V. Phone/Fax

Practice location:
  • Phone: 858-455-6460
  • Fax: 858-455-7197
Mailing address:
  • Phone: 858-455-6460
  • Fax: 858-455-7197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License NumberG76060
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: