Individual
DR. KEVIN JAY CHILDERS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
OD
Contact information
Practice address
2202 W RANDOLPH ST, VANDALIA, IL 62471-1946
(618) 283-3511
(618) 283-1815
Mailing address
PO BOX 320, VANDALIA, IL 62471-0320
(618) 283-3511
(618) 283-1815
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
046-007658
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
046007658
—
IL
01
—
205184
EYE MED
IL
01
—
2684002
BLUE CROSS/BLUE SHIELD
IL
01
—
3672C
CATERPILLAR
IL
01
—
6182833511
VSP
IL
01
—
WPS76001
ELEC MED PROC
IL
Enumeration date
10/18/2006
Last updated
05/01/2008
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