Provider Demographics
NPI:1649732504
Name:CHILDS, OLIVIA (DO)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:CHILDS
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 N LA SALLE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-2730
Mailing Address - Country:US
Mailing Address - Phone:608-553-1453
Mailing Address - Fax:
Practice Address - Street 1:415 N LA SALLE DR STE 100
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-2730
Practice Address - Country:US
Practice Address - Phone:888-663-6331
Practice Address - Fax:415-252-7176
Is Sole Proprietor?:No
Enumeration Date:2019-04-01
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL036158952207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1649732504Medicaid