Healthcare Provider Details

I. General information

NPI: 1144247842
Provider Name (Legal Business Name): KIMBERLY LYNN SKIDMORE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 06/06/2023
Certification Date: 09/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1541 KINGS HWY
SHREVEPORT LA
71103-4228
US

IV. Provider business mailing address

1512 W KIRBY PL
SHREVEPORT LA
71103-3822
US

V. Phone/Fax

Practice location:
  • Phone: 318-626-0000
  • Fax: 318-629-4833
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA60796
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberN9133
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License Number207585
License Number StateLA
# 4
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number207585
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: