Basic Information
Provider Information | |||||||||
NPI: | 1770675738 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DOUGLAS | ||||||||
FirstName: | KIMBERLY | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CORRAL | ||||||||
OtherFirstName: | KIMBERLY | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 43 | ||||||||
Address2: |   | ||||||||
City: | KOTZEBUE | ||||||||
State: | AK | ||||||||
PostalCode: | 997520043 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9072234365 | ||||||||
FaxNumber: | 9074427306 | ||||||||
Practice Location | |||||||||
Address1: | 436 5TH & TED STEVENS WAY | ||||||||
Address2: |   | ||||||||
City: | KOTZEBUE | ||||||||
State: | AK | ||||||||
PostalCode: | 997520043 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9074423321 | ||||||||
FaxNumber: | 9074427250 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/28/2006 | ||||||||
LastUpdateDate: | 07/29/2011 | ||||||||
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 | 207Q00000X | 6568 | AK | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | HS19IP | 05 | AK |   | MEDICAID | HS19OP | 05 | AK |   | MEDICAID |