Provider Demographics
NPI:1003871815
Name:KINGMA, DOUGLAS W (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:W
Last Name:KINGMA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2004 HAYES ST
Mailing Address - Street 2:STE 800
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-2659
Mailing Address - Country:US
Mailing Address - Phone:615-514-6963
Mailing Address - Fax:615-986-0560
Practice Address - Street 1:448 CAROTHERS PARKWAY
Practice Address - Street 2:SUITE 310
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37067
Practice Address - Country:US
Practice Address - Phone:615-986-4330
Practice Address - Fax:615-550-4320
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-18
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD430689207ZP0101X
MI4301081425207ZP0105X
NJ25MA08843800207ZH0000X
OK17073207ZP0101X
TN46486207ZH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematologyGroup - Multi-Specialty
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic PathologyGroup - Multi-Specialty
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4550124Medicaid
MI4550124Medicaid
H94306Medicare UPIN