Provider Demographics
NPI:1033182811
Name:CHILDERS, ALONZO (MD)
Entity Type:Individual
Prefix:
First Name:ALONZO
Middle Name:
Last Name:CHILDERS
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 1:1120 E ELIZABETH ST
Mailing Address - Street 2:F-101
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-4044
Mailing Address - Country:US
Mailing Address - Phone:970-221-1177
Mailing Address - Fax:970-416-1969
Practice Address - Street 1:3820 N GRANT AVE
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-8412
Practice Address - Country:US
Practice Address - Phone:970-593-1177
Practice Address - Fax:970-593-0470
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO21678207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01216787Medicaid
CO01216787Medicaid
D23972Medicare UPIN