Healthcare Provider Details

I. General information

NPI: 1679567986
Provider Name (Legal Business Name): EDWARD L CHILDERS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2005
Last Update Date: 12/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3825 EUBANK BLVD NE STE C
ALBUQUERQUE NM
87111-3575
US

IV. Provider business mailing address

3825 EUBANK BLVD NE STE C
ALBUQUERQUE NM
87111-3575
US

V. Phone/Fax

Practice location:
  • Phone: 505-298-8020
  • Fax: 505-292-5006
Mailing address:
  • Phone: 505-298-8020
  • Fax: 505-292-5006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA65376
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: