Provider Demographics
NPI:1407891930
Name:CHAMBERLAIN, CHRISTINA WALLIS (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTINA
Middle Name:WALLIS
Last Name:CHAMBERLAIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5955 PONCE DE LEON BLVD
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33146-2423
Mailing Address - Country:US
Mailing Address - Phone:305-661-1515
Mailing Address - Fax:305-662-3723
Practice Address - Street 1:5955 PONCE DE LEON BLVD
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33146-2423
Practice Address - Country:US
Practice Address - Phone:305-661-1515
Practice Address - Fax:305-662-3723
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-18
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL2179208000000X, 2080N0001X
NMRS2004-06282080N0001X
FLME1380652080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX143487002Medicaid
TX143487004Medicaid
TX143487003Medicaid
TX143487001Medicaid