Provider Demographics
NPI:1487645065
Name:MOULDS, KEITH RONALD (OD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:RONALD
Last Name:MOULDS
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 1:4643 ALPINE AVE NW
Mailing Address - Street 2:A
Mailing Address - City:COMSTOCK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:49321-8179
Mailing Address - Country:US
Mailing Address - Phone:616-784-8700
Mailing Address - Fax:616-784-8708
Practice Address - Street 1:4643 ALPINE AVE NW
Practice Address - Street 2:A
Practice Address - City:COMSTOCK PARK
Practice Address - State:MI
Practice Address - Zip Code:49321-8179
Practice Address - Country:US
Practice Address - Phone:616-784-8700
Practice Address - Fax:616-784-8708
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004021152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI944431615Medicaid
MI944431615Medicaid
MI1275516155Medicare NSC