Provider Demographics
NPI:1265477509
Name:CHIN-LENN, MARK DERRICK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DERRICK
Last Name:CHIN-LENN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4040 SHERIDAN ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-3536
Mailing Address - Country:US
Mailing Address - Phone:954-322-7166
Mailing Address - Fax:954-322-7169
Practice Address - Street 1:4040 SHERIDAN ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-3536
Practice Address - Country:US
Practice Address - Phone:954-322-7166
Practice Address - Fax:954-322-7169
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME89650207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113572100Medicaid
FLME89650OtherMEDICAL LICENSE
FLBC8671491OtherDEA