Provider Demographics
NPI:1629038419
Name:KINGMA, PHILLIP R (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:R
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 1:12289 HANCOCK ST STE 34
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-5888
Mailing Address - Country:US
Mailing Address - Phone:317-815-8950
Mailing Address - Fax:317-815-8951
Practice Address - Street 1:12289 HANCOCK ST STE 34
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-5888
Practice Address - Country:US
Practice Address - Phone:317-815-8950
Practice Address - Fax:317-815-8951
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040487208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ININ01040487OtherIN LIC #
IN208391569OtherTAX ID #
OH35.088877OtherOH LIC #
OH35.088877OtherOH LIC #
IN6721010001Medicare NSC