Healthcare Provider Details

I. General information

NPI: 1598077430
Provider Name (Legal Business Name): KIMBERLY RAYE MCDONALD M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2010
Last Update Date: 12/21/2022
Certification Date: 12/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 E CHESTNUT ST # STREET2
LOUISVILLE KY
40202-1713
US

IV. Provider business mailing address

PO BOX 776879
CHICAGO IL
60677-6879
US

V. Phone/Fax

Practice location:
  • Phone: 502-588-0850
  • Fax:
Mailing address:
  • Phone: 502-588-9490
  • Fax: 502-272-5339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number25161
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25161
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number25161
License Number StateMS
# 4
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number57529
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: