Provider Demographics
NPI:1598714313
Name:KIMMEL, SANDY JEAN (DO)
Entity type:Individual
Prefix:DR
First Name:SANDY
Middle Name:JEAN
Last Name:KIMMEL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 EXECUTIVE DR
Mailing Address - Street 2:SUITE 203
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-7476
Mailing Address - Country:US
Mailing Address - Phone:919-872-0390
Mailing Address - Fax:919-872-0391
Practice Address - Street 1:3400 EXECUTIVE DR
Practice Address - Street 2:SUITE 203
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7476
Practice Address - Country:US
Practice Address - Phone:919-872-0390
Practice Address - Fax:919-872-0391
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-09
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2004008932084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89137PCMedicaid
NC137PCOtherBLUE CROSS/BLUE SHIELD
NC115766Medicare UPIN
NC2402208Medicare ID - Type Unspecified