Healthcare Provider Details

I. General information

NPI: 1790717692
Provider Name (Legal Business Name): KIMBERLY ADAMS BOUVETTE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 12/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4120 W MEMORIAL RD STE 118
OKLAHOMA CITY OK
73120-9322
US

IV. Provider business mailing address

4120 W MEMORIAL RD STE 118
OKLAHOMA CITY OK
73120-9322
US

V. Phone/Fax

Practice location:
  • Phone: 405-748-4700
  • Fax: 405-748-5638
Mailing address:
  • Phone: 405-748-4700
  • Fax: 405-748-5638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number20425
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number20425
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: