Provider Demographics
NPI:1750383188
Name:CHAN, KIM-KING (MD)
Entity type:Individual
Prefix:DR
First Name:KIM-KING
Middle Name:
Last Name:CHAN
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 1:66 W GILBERT ST
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-4918
Mailing Address - Country:US
Mailing Address - Phone:732-212-0051
Mailing Address - Fax:732-212-0713
Practice Address - Street 1:718 TEANECK ROAD
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666
Practice Address - Country:US
Practice Address - Phone:201-833-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03194200207P00000X, 207R00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5425301Medicaid
PAP00766578OtherRR MEDICARE
NJP00674579OtherRAIL ROAD MEDICARE
NJ521900P7DMedicare PIN
NJ521900CLDMedicare PIN
PAP00766578OtherRR MEDICARE
NJE53117Medicare UPIN
NJ521900SNYMedicare PIN
NJ521900UXXMedicare PIN
NJ521900UWXMedicare PIN
NJ521900ZC79Medicare PIN
NJ158450ZC79Medicare PIN
NJ521900MK3Medicare PIN
NJ5425301Medicaid
NJ521900P7EMedicare PIN
NJ158450UWXMedicare PIN