Healthcare Provider Details

I. General information

NPI: 1295709483
Provider Name (Legal Business Name): MICHAEL CHILDS DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 12/22/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2316 W CHARLESTON BLVD
LAS VEGAS NV
89102-2149
US

IV. Provider business mailing address

PO BOX 15645
LAS VEGAS NV
89114-5645
US

V. Phone/Fax

Practice location:
  • Phone: 702-877-8600
  • Fax: 702-240-8790
Mailing address:
  • Phone: 702-240-8847
  • Fax: 702-240-8790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number75904
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: