Provider Demographics
NPI:1548333859
Name:MAULL, KIMBALL IVAN (MD)
Entity type:Individual
Prefix:DR
First Name:KIMBALL
Middle Name:IVAN
Last Name:MAULL
Suffix:
Gender:M
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:1600 CARRAWAY BLVD
Mailing Address - Street 2:CARRAWAY PHYSICIANS PLAZA SUITE 200
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35234-1913
Mailing Address - Country:US
Mailing Address - Phone:205-502-3602
Mailing Address - Fax:205-502-3601
Practice Address - Street 1:1600 CARRAWAY BLVD
Practice Address - Street 2:CARRAWAY PHYSICIANS PLAZA SUITE 200
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35234-1913
Practice Address - Country:US
Practice Address - Phone:205-502-3600
Practice Address - Fax:205-502-3601
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ALAL22133208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
A96757Medicare UPIN
AL51098518Medicare ID - Type Unspecified