Provider Demographics
NPI:1720002280
Name:CHILDS-LOVE, MISHUN DELIESE (MD, PHD)
Entity Type:Individual
Prefix:
First Name:MISHUN
Middle Name:DELIESE
Last Name:CHILDS-LOVE
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:MISHUN
Other - Middle Name:DELIESE
Other - Last Name:CHILDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 660857
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75266-0857
Mailing Address - Country:US
Mailing Address - Phone:855-709-4498
Mailing Address - Fax:302-733-0854
Practice Address - Street 1:1900 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48708-6880
Practice Address - Country:US
Practice Address - Phone:989-984-3077
Practice Address - Fax:989-894-6138
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301060250207L00000X
OH35.081724207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0500910292OtherBCBS
G34777Medicare UPIN
MI0500910292OtherBCBS