Healthcare Provider Details

I. General information

NPI: 1659356343
Provider Name (Legal Business Name): MONIQUE L. CHILD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 W TUDOR RD
ANCHORAGE AK
99503
US

IV. Provider business mailing address

603 W TUDOR RD
ANCHORAGE AK
99503
US

V. Phone/Fax

Practice location:
  • Phone: 907-522-5437
  • Fax: 907-522-5435
Mailing address:
  • Phone: 907-522-5437
  • Fax: 907-522-5435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036108167
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number6196
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier336069066
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerCTL SUBS LICENSE
# 2
Identifier036108167
Identifier TypeMEDICAID
Identifier StateIL
Identifier Issuer
# 3
Identifier43083
Identifier TypeOTHER
Identifier StateCO
Identifier IssuerCOLORADO STATE LICENSE
# 4
Identifier036108167
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerSTATE LICENSE
# 5
Identifier1020541
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: