Provider Demographics
NPI:1922028067
Name:CHIN, KELLY (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:CHIN
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 1:93 BROWN CIR
Mailing Address - Street 2:
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652-5203
Mailing Address - Country:US
Mailing Address - Phone:718-871-2511
Mailing Address - Fax:
Practice Address - Street 1:829 57TH ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-3617
Practice Address - Country:US
Practice Address - Phone:718-871-2511
Practice Address - Fax:718-871-0062
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY195950174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01774758Medicaid
NY27N861Medicare ID - Type Unspecified
NY01774758Medicaid