Healthcare Provider Details

I. General information

NPI: 1629293493
Provider Name (Legal Business Name): KIMBERLEY R. LOVELACE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIMBERLEY R. BAKER

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 05/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3524 E MILWAUKEE ST
JANESVILLE WI
53546-1626
US

IV. Provider business mailing address

3524 E MILWAUKEE ST
JANESVILLE WI
53546-1626
US

V. Phone/Fax

Practice location:
  • Phone: 608-756-7110
  • Fax: 608-756-7106
Mailing address:
  • Phone: 608-756-7110
  • Fax: 608-756-7106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number# 390200000X
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberDR.51421
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number50588-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: