Healthcare Provider Details

I. General information

NPI: 1447240155
Provider Name (Legal Business Name): KIMBERLEE H OVERDECK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAUREN KIMBERLEE HORTON MD

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 11/27/2023
Certification Date: 11/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1112 SHIPMAN LANE
MCLEAN VA
22101-2137
US

IV. Provider business mailing address

111 OAKWOOD RD
EAST PEORIA IL
61611-1853
US

V. Phone/Fax

Practice location:
  • Phone: 703-556-6466
  • Fax: 703-556-8881
Mailing address:
  • Phone: 309-740-4272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036-134226
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberD0061784
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0101240648
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: