Provider Demographics
NPI:1023046521
Name:CHIN, KINGSLEY R (MD)
Entity Type:Individual
Prefix:DR
First Name:KINGSLEY
Middle Name:R
Last Name:CHIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1100 W OAKLAND PARK BLVD
Mailing Address - Street 2:SUITE #3
Mailing Address - City:WILTON MANORS
Mailing Address - State:FL
Mailing Address - Zip Code:33311-1612
Mailing Address - Country:US
Mailing Address - Phone:561-822-2960
Mailing Address - Fax:877-647-7874
Practice Address - Street 1:3816 HOLLYWOOD BLVD STE 102
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-6750
Practice Address - Country:US
Practice Address - Phone:954-640-6010
Practice Address - Fax:855-411-4647
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA10203200207X00000X
FLME90952207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001901396Medicaid
PA001901396Medicaid
H53148Medicare UPIN