Provider Demographics
NPI:1750676938
Name:CHILDERS, JOSEPH MICHAEL
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:MICHAEL
Last Name:CHILDERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 357054
Mailing Address - Street 2:SAN CLEMENTE ISLAND BRANCH MEDICAL CLINIC
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:92135-7054
Mailing Address - Country:US
Mailing Address - Phone:619-524-9356
Mailing Address - Fax:619-524-9207
Practice Address - Street 1:SEAL TEAM THREE MEDICAL
Practice Address - Street 2:2642 TRIDENT WAY
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92155-5492
Practice Address - Country:US
Practice Address - Phone:619-524-9356
Practice Address - Fax:619-524-9207
Is Sole Proprietor?:No
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman