Provider Demographics
NPI:1679567986
Name:CHILDERS, EDWARD L (DO)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:L
Last Name:CHILDERS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3825 EUBANK BLVD NE
Mailing Address - Street 2:STE C
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-3575
Mailing Address - Country:US
Mailing Address - Phone:505-298-8020
Mailing Address - Fax:505-292-5006
Practice Address - Street 1:3825 EUBANK BLVD NE
Practice Address - Street 2:STE C
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-3575
Practice Address - Country:US
Practice Address - Phone:505-298-8020
Practice Address - Fax:505-292-5006
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-01
Last Update Date:2010-12-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NMA65376207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C99446Medicare UPIN