Basic Information
| Provider Information | |||||||||
| NPI: | 1073503603 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIMBALL | ||||||||
| FirstName: | ALEXANDRA | ||||||||
| MiddleName: | BOER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD MPH | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KIMBALL | ||||||||
| OtherFirstName: | ALEXANDRA | ||||||||
| OtherMiddleName: | BOER | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD MPH | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 375 LONGWOOD AVE STE 3 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022155395 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176327444 | ||||||||
| FaxNumber: | 6177267768 | ||||||||
| Practice Location | |||||||||
| Address1: | 330 BROOKLINE AVE | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176673753 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2005 | ||||||||
| LastUpdateDate: | 05/29/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 222718 | MA | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 469829 | 01 | MA | TUFTS HEALTH PLAN | OTHER | 2083850 | 05 | MA | MEDICAID | J28105 | 01 | MA | BCBS MA | OTHER |