Provider Demographics
NPI:1134157605
Name:CHILDRESS, JOHN M (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:M
Last Name:CHILDRESS
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 1:550 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-6402
Mailing Address - Country:US
Mailing Address - Phone:212-263-3293
Mailing Address - Fax:212-263-3522
Practice Address - Street 1:550 1ST AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6402
Practice Address - Country:US
Practice Address - Phone:212-263-3293
Practice Address - Fax:212-263-3522
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME95727207P00000X
OH35 123788207P00000X
FLME 95727207XX0005X, 2081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPENDINGMedicaid
FLPENDINGOtherBLUE SHIELD OF FL
I32503Medicare UPIN
FLPENDINGOtherBLUE SHIELD OF FL