Provider Demographics
NPI:1134133929
Name:MOLINE, DAVID CHARLES (OD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:CHARLES
Last Name:MOLINE
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 1:36 W 10TH STREET
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376
Mailing Address - Country:US
Mailing Address - Phone:209-835-7446
Mailing Address - Fax:209-835-3572
Practice Address - Street 1:36 W 10TH STREET
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376
Practice Address - Country:US
Practice Address - Phone:209-835-7446
Practice Address - Fax:209-835-3572
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7528152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD075281Medicaid
CAT10552Medicare UPIN
CA5482220001Medicare NSC
CAZZZ31017ZMedicare PIN