Provider Demographics
NPI:1932287471
Name:CHILDERS, BEN J (MD)
Entity Type:Individual
Prefix:DR
First Name:BEN
Middle Name:J
Last Name:CHILDERS
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 1:4605 BROCKTON AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-0106
Mailing Address - Country:US
Mailing Address - Phone:951-781-4366
Mailing Address - Fax:951-274-0985
Practice Address - Street 1:4605 BROCKTON AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-0106
Practice Address - Country:US
Practice Address - Phone:951-781-4366
Practice Address - Fax:951-274-0985
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG76953174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA200975173OtherTAX ID
CA200975173OtherTAX ID
CAY09156Medicare UPIN