Provider Demographics
NPI:1548242076
Name:CHILD, CLELAND G (MD)
Entity type:Individual
Prefix:
First Name:CLELAND
Middle Name:G
Last Name:CHILD
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 1:888 S KING ST
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813-3097
Mailing Address - Country:US
Mailing Address - Phone:770-400-7700
Mailing Address - Fax:
Practice Address - Street 1:888 S KING ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-3097
Practice Address - Country:US
Practice Address - Phone:808-582-1331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI24360207R00000X
GA030589208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00408768FMedicaid
GA11BDGJMMedicare ID - Type Unspecified
GA00408768FMedicaid