Individual
KIM W. WATERFALL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
5571 CHOWNING WAY, COLUMBUS, OH 43213-1479
(614) 625-6621
Mailing address
5571 CHOWNING WAY, COLUMBUS, OH 43213-1479
(614) 625-6621
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
090079
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000111941
ANTHEM
IN
01
—
00000499190 04
UNITED HEALTHCARE
—
05
—
200115550
—
IN
01
—
3937240020
MEDICARE DMEPOS
IN
01
—
5736320
AETNA
—
01
—
7336
PHYSICIANS HAELTH PLAN
IN
Enumeration date
12/29/2005
Last updated
04/13/2009
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