Provider Demographics
NPI:1114906310
Name:CHILDERS, KERRY K (OD)
Entity Type:Individual
Prefix:DR
First Name:KERRY
Middle Name:K
Last Name:CHILDERS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:723 FALLS BLVD S
Mailing Address - Street 2:STE A
Mailing Address - City:WYNNE
Mailing Address - State:AR
Mailing Address - Zip Code:72396-3508
Mailing Address - Country:US
Mailing Address - Phone:870-238-2020
Mailing Address - Fax:870-238-4320
Practice Address - Street 1:723 FALLS BLVD S
Practice Address - Street 2:STE A
Practice Address - City:WYNNE
Practice Address - State:AR
Practice Address - Zip Code:72396-3508
Practice Address - Country:US
Practice Address - Phone:870-238-2020
Practice Address - Fax:870-238-4320
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-16
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2038152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR102042722Medicaid
AR64772430001OtherPTAN
AR64772430001OtherPTAN
T20126Medicare UPIN