Provider Demographics
NPI:1063492304
Name:CHILD, GARY L (DO)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:L
Last Name:CHILD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:945 W 3200 N
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-9771
Mailing Address - Country:US
Mailing Address - Phone:801-766-6055
Mailing Address - Fax:888-611-8840
Practice Address - Street 1:945 W 3200 N
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-9771
Practice Address - Country:US
Practice Address - Phone:801-766-6055
Practice Address - Fax:888-611-8840
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-20
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT71112893-1204207QG0300X, 207QH0002X, 208VP0014X
UT7112893-1204207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1063492304Medicaid
UT1063492304Medicaid