Provider Demographics
NPI:1831154574
Name:HUMULOCK, KIMBERLY J (DO)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:J
Last Name:HUMULOCK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:190 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-2430
Mailing Address - Country:US
Mailing Address - Phone:401-921-5970
Mailing Address - Fax:401-921-5973
Practice Address - Street 1:190 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-2430
Practice Address - Country:US
Practice Address - Phone:401-492-1597
Practice Address - Fax:401-921-5973
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-18
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDO00521207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7936235OtherAETNA HEALTH CARE
PR454709OtherTUFTS HEALTH PLAN
RI04-0336OtherUNITEDHEALTH CARE
RI407435OtherBLUE CHIP
RI22405-7OtherBLUE CROSS & BLUE SHIELD
RI9022405Medicaid
RI04-0336OtherUNITEDHEALTH CARE
RI119022405Medicare PIN