Basic Information
Provider Information | |||||||||
NPI: | 1295728228 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WALDROP | ||||||||
FirstName: | KIMBERLY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | AU.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | METCALF | ||||||||
OtherFirstName: | KIMBERLY | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | AU.D. | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 19950 HUEBNER RD | ||||||||
Address2: | #506 | ||||||||
City: | SAN ANTONIO | ||||||||
State: | TX | ||||||||
PostalCode: | 782583292 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2106175300 | ||||||||
FaxNumber: | 2106175200 | ||||||||
Practice Location | |||||||||
Address1: | 7400 MERTON MINTER BLVD | ||||||||
Address2: |   | ||||||||
City: | SAN ANTONIO | ||||||||
State: | TX | ||||||||
PostalCode: | 782294404 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2106175300 | ||||||||
FaxNumber: | 2106175200 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/24/2005 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 51238 | TX | Y |   | Speech, Language and Hearing Service Providers | Audiologist |   |
ID Information
ID | Type | State | Issuer | Description | P00134880 | 01 | TX | MEDICARE RAILROAD | OTHER | 80290A | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER |