Provider Demographics
NPI:1659617439
Name:IGBINOSUN, KINGSLEY
Entity Type:Individual
Prefix:
First Name:KINGSLEY
Middle Name:
Last Name:IGBINOSUN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1655 CHASE RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-4369
Mailing Address - Country:US
Mailing Address - Phone:404-431-6829
Mailing Address - Fax:
Practice Address - Street 1:1655 CHASE RIDGE LN
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-4369
Practice Address - Country:US
Practice Address - Phone:404-431-6829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-22
Last Update Date:2012-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies