Provider Demographics
NPI:1306927181
Name:CHILDERS, KEVIN JAY (OD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JAY
Last Name:CHILDERS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 320
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62471-0320
Mailing Address - Country:US
Mailing Address - Phone:618-283-3511
Mailing Address - Fax:618-283-1815
Practice Address - Street 1:2202 W RANDOLPH ST
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:IL
Practice Address - Zip Code:62471-1946
Practice Address - Country:US
Practice Address - Phone:618-283-3511
Practice Address - Fax:618-283-1815
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-007658152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3672COtherCATERPILLAR
IL2684002OtherBLUE CROSS/BLUE SHIELD
IL205184OtherEYE MED
IL046007658Medicaid
ILWPS76001OtherELEC MED PROC
IL6182833511OtherVSP
ILT38118Medicare UPIN
IL0711240001Medicare NSC
IL3672COtherCATERPILLAR
IL046007658Medicaid