Provider Demographics
NPI:1184675498
Name:CHILDERS, BRIAN KEITH (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:KEITH
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 1:100 DOCTORS DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-2210
Mailing Address - Country:US
Mailing Address - Phone:912-383-4352
Mailing Address - Fax:912-384-1192
Practice Address - Street 1:100 DOCTORS DR
Practice Address - Street 2:SUITE 104
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2210
Practice Address - Country:US
Practice Address - Phone:912-383-4352
Practice Address - Fax:912-384-1192
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042212208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics