Provider Demographics
NPI:1700196599
Name:RICHARD C CHILDERS MD PA
Entity Type:Organization
Organization Name:RICHARD C CHILDERS MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:CHILDERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-331-0418
Mailing Address - Street 1:928 NW 57TH ST
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-4482
Mailing Address - Country:US
Mailing Address - Phone:352-331-0418
Mailing Address - Fax:352-331-0133
Practice Address - Street 1:928 NW 57TH ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-4482
Practice Address - Country:US
Practice Address - Phone:352-331-0418
Practice Address - Fax:352-331-0133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-14
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0017669207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLES931AMedicare PIN