Basic Information
| Provider Information | |||||||||
| NPI: | 1174609556 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIMBALL | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10470 OLD PLACERVILLE RD | ||||||||
| Address2: | #100 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958272539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8666810736 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2 MEDICAL PLAZA DR | ||||||||
| Address2: | #205 | ||||||||
| City: | ROSEVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956613043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167738711 | ||||||||
| FaxNumber: | 9167738712 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2006 | ||||||||
| LastUpdateDate: | 08/07/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | ME103822 | FL | Y | Allopathic & Osteopathic Physicians | Neurological Surgery | 207T00000X | TRN10275 | FL | N | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 007180500 | 05 | FL | MEDICAID | ME103822 | 01 | FL | FLORIDA LICENSE | OTHER | AD9470826-510487 | 01 | FL | DEA# | OTHER | FK1838145 | 01 | FL | FLORIDA DEA | OTHER |