Provider Demographics
NPI:1497716559
Name:CHILDERS, GARY BLANE (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:BLANE
Last Name:CHILDERS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:4711 OPUS DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-8694
Mailing Address - Country:US
Mailing Address - Phone:719-579-0900
Mailing Address - Fax:719-579-0911
Practice Address - Street 1:4711 OPUS DR
Practice Address - Street 2:SUITE 201
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-8694
Practice Address - Country:US
Practice Address - Phone:719-579-0900
Practice Address - Fax:719-579-0911
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-29
Last Update Date:2013-05-13
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Provider Licenses
StateLicense IDTaxonomies
CO30910207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
COE35408Medicare UPIN