Basic Information
| Provider Information | |||||||||
| NPI: | 1871772202 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIMBROUGH | ||||||||
| FirstName: | W | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1014 SAINT CLAIR BLVD | ||||||||
| Address2: | SUITE 3015 | ||||||||
| City: | GONZALES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707375023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257432455 | ||||||||
| FaxNumber: | 2256445213 | ||||||||
| Practice Location | |||||||||
| Address1: | 1014 SAINT CLAIR BLVD | ||||||||
| Address2: | SUITE 3015 | ||||||||
| City: | GONZALES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707375023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257432455 | ||||||||
| FaxNumber: | 2256445213 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2007 | ||||||||
| LastUpdateDate: | 03/31/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | MD202378 | LA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1508543 | 05 | LA | MEDICAID |