Provider Demographics
NPI:1457462319
Name:COUILLARD, DAVID R (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:R
Last Name:COUILLARD
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 1:584 N SUNRISE AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-2862
Mailing Address - Country:US
Mailing Address - Phone:916-251-3063
Mailing Address - Fax:916-459-2403
Practice Address - Street 1:584 N SUNRISE AVE STE 100
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-2862
Practice Address - Country:US
Practice Address - Phone:916-251-3063
Practice Address - Fax:916-459-2403
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG68651208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ26454ZOtherMEDICARE GROUP PTAN
CA00G686510Medicaid
CAZZZ26454ZOtherMEDICARE GROUP PTAN
F38442Medicare UPIN