Basic Information
Provider Information
NPI: 1487614228
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: CHILDERS
FirstName: MANON
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 3006 GARRETT DR
Address2:  
City: PERRYTON
State: TX
PostalCode: 790705322
CountryCode: US
TelephoneNumber: 8064356856
FaxNumber: 8064354175
Practice Location
Address1: 3101 GARRETT DR
Address2:  
City: PERRYTON
State: TX
PostalCode: 790705323
CountryCode: US
TelephoneNumber: 8064353606
FaxNumber: 8064352067
Other Information
ProviderEnumerationDate: 03/24/2006
LastUpdateDate: 10/07/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 10/07/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000XG4911TXY Allopathic & Osteopathic PhysiciansFamily Medicine 

ID Information
IDTypeStateIssuerDescription
13297080305TX MEDICAID


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