1124009337 NPI number — RICHARD L CHILDERS DPM

Table of content: RICHARD L CHILDERS DPM (NPI 1124009337)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124009337 NPI number — RICHARD L CHILDERS DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHILDERS
Provider First Name:
RICHARD
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124009337
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/10/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5825 CALLAGHAN RD STE 102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78228-1106
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-227-8700
Provider Business Mailing Address Fax Number:
210-348-9130

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
28590 IH 10 WEST
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
BOERNE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
830-981-5150
Provider Business Practice Location Address Fax Number:
830-981-5159
Provider Enumeration Date:
11/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  0930 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 130989007 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8D1393 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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