Basic Information
| Provider Information | |||||||||
| NPI: | 1396722146 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAXTER | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | VAIL | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12221 N MOPAC EXPY | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787582401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5129014016 | ||||||||
| FaxNumber: | 5129013857 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 MEDICAL PKWY STE 150 | ||||||||
| Address2: | |||||||||
| City: | CEDAR PARK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786135026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5129014038 | ||||||||
| FaxNumber: | 5129013976 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2005 | ||||||||
| LastUpdateDate: | 02/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | J8435 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 102963901 | 05 | TX | MEDICAID |