Provider Demographics
NPI:1174611966
Name:CHILDERS, JEFFREY W (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:W
Last Name:CHILDERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 S MOUNT AUBURN RD
Mailing Address - Street 2:SUITE 342
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-4910
Mailing Address - Country:US
Mailing Address - Phone:573-335-2212
Mailing Address - Fax:573-339-5946
Practice Address - Street 1:150 S MOUNT AUBURN RD
Practice Address - Street 2:SUITE 342
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-4910
Practice Address - Country:US
Practice Address - Phone:573-335-2212
Practice Address - Fax:573-339-5946
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001004971207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205303019Medicaid
MOH37154Medicare UPIN
MO002014420Medicare ID - Type UnspecifiedMEDICARE ID NUMBER