Provider Demographics
NPI:1144545096
Name:KIMBRELL, BLAKE STEVEN (MD)
Entity type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:STEVEN
Last Name:KIMBRELL
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 1:150 NACOOCHEE AVE
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30601-1823
Mailing Address - Country:US
Mailing Address - Phone:706-546-7908
Mailing Address - Fax:706-546-1944
Practice Address - Street 1:150 NACOOCHEE AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30601-1823
Practice Address - Country:US
Practice Address - Phone:706-546-7908
Practice Address - Fax:706-546-1944
Is Sole Proprietor?:No
Enumeration Date:2010-04-05
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA262561207Y00000X
VA0101258556207Y00000X
GA75683207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003176590AMedicaid