Provider Demographics
NPI:1346386174
Name:KINGMAN FAMILY PRACTICE, P.C.
Entity Type:Organization
Organization Name:KINGMAN FAMILY PRACTICE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:FRANK
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:928-529-7744
Mailing Address - Street 1:3880 N STOCKTON HILL RD STE 103135
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-0595
Mailing Address - Country:US
Mailing Address - Phone:928-529-7744
Mailing Address - Fax:928-757-2437
Practice Address - Street 1:2812 SILVER CREEK RD
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-8309
Practice Address - Country:US
Practice Address - Phone:928-763-1404
Practice Address - Fax:928-763-9795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2019-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4550207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ185299Medicaid
AZDG2348OtherRAILROAD MEDICARE
AZZ116536OtherMEDICARE PTAN
AZ185299Medicaid
AZ116536Medicare PIN
BB1889546OtherDEA