Healthcare Provider Details

I. General information

NPI: 1578589842
Provider Name (Legal Business Name): KELLY L WIMBERLY MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 07/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17101 PRESTON RD SUITE 200
DALLAS TX
75248-1331
US

IV. Provider business mailing address

17101 PRESTON RD SUITE 200
DALLAS TX
75248-1331
US

V. Phone/Fax

Practice location:
  • Phone: 972-239-4441
  • Fax: 972-239-1597
Mailing address:
  • Phone: 972-239-4441
  • Fax: 972-239-1597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberJ3002
License Number StateTX

VIII. Authorized Official

Name: DR. KELLY L WIMBERLY
Title or Position: OWNER
Credential: MD
Phone: 972-239-4441