Healthcare Provider Details

I. General information

NPI: 1659784726
Provider Name (Legal Business Name): BENJAMIN ALAN CHILDERS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2014
Last Update Date: 06/18/2024
Certification Date: 06/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 N 2ND ST
OZARK MO
65721-9366
US

IV. Provider business mailing address

359 S COUNTRYMAN RD
OZARK MO
65721-7695
US

V. Phone/Fax

Practice location:
  • Phone: 417-844-8726
  • Fax:
Mailing address:
  • Phone: 417-838-3290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number2021027634
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number2021027634
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: