Healthcare Provider Details

I. General information

NPI: 1144696220
Provider Name (Legal Business Name): KINGSKIDS PHYSICIANS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2015
Last Update Date: 08/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13932 BALTIMORE AVE 11
LAUREL MD
20707-5000
US

IV. Provider business mailing address

13932 BALTIMORE AVE 11
LAUREL MD
20707-5000
US

V. Phone/Fax

Practice location:
  • Phone: 443-653-1229
  • Fax: 410-315-7868
Mailing address:
  • Phone: 443-653-1229
  • Fax: 410-315-7868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberD0064420
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier335147500
Identifier TypeMEDICAID
Identifier StateMD
Identifier Issuer

VIII. Authorized Official

Name: MR. SUNDAY CHUKS OKPARAOCHA
Title or Position: OFFICE MANAGER
Credential:
Phone: 443-653-1229