Provider Demographics
NPI:1639791379
Name:DAVIS, KIMBERLY DIANE (DO)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DIANE
Last Name:DAVIS
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 1:71 HAYNES ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-4131
Mailing Address - Country:US
Mailing Address - Phone:860-533-4679
Mailing Address - Fax:860-645-4151
Practice Address - Street 1:13 CHURCH RD
Practice Address - Street 2:
Practice Address - City:EAST GRANBY
Practice Address - State:CT
Practice Address - Zip Code:06026-9406
Practice Address - Country:US
Practice Address - Phone:860-653-4526
Practice Address - Fax:833-471-6186
Is Sole Proprietor?:No
Enumeration Date:2020-05-15
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT75672207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine