Provider Demographics
NPI:1902888704
Name:CHIN, KENNETH W (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:W
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 1:18133 VENTURA BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-3641
Mailing Address - Country:US
Mailing Address - Phone:818-933-2020
Mailing Address - Fax:818-817-7668
Practice Address - Street 1:18133 VENTURA BLVD STE 100
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3641
Practice Address - Country:US
Practice Address - Phone:818-933-2020
Practice Address - Fax:818-817-7668
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-17
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG296602085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G296600Medicaid
CAWG29660DMedicare PIN
A44101Medicare UPIN