Provider Demographics
NPI:1902122203
Name:KIMMELL, KRISTOPHER T (MD)
Entity Type:Individual
Prefix:
First Name:KRISTOPHER
Middle Name:T
Last Name:KIMMELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2655 RIDGEWAY AVE STE 340
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-4296
Mailing Address - Country:US
Mailing Address - Phone:585-368-6545
Mailing Address - Fax:585-368-6546
Practice Address - Street 1:2655 RIDGEWAY AVE STE 340
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-4296
Practice Address - Country:US
Practice Address - Phone:585-368-6545
Practice Address - Fax:585-368-6546
Is Sole Proprietor?:No
Enumeration Date:2010-04-12
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY285417207T00000X
390200000X
MO2016035825207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1902122203Medicaid