Provider Demographics
NPI:1659379923
Name:CHILD, DOUGLAS D (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:D
Last Name:CHILD
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 1:232 E 300 N
Mailing Address - Street 2:
Mailing Address - City:MIDWAY
Mailing Address - State:UT
Mailing Address - Zip Code:84049-6917
Mailing Address - Country:US
Mailing Address - Phone:435-760-3968
Mailing Address - Fax:
Practice Address - Street 1:1151 E 3900 S
Practice Address - Street 2:B150
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1216
Practice Address - Country:US
Practice Address - Phone:801-262-3441
Practice Address - Fax:801-269-9005
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT170121-12052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
842911Medicare UPIN
UT005751301Medicare ID - Type Unspecified