Provider Demographics
NPI:1255351748
Name:MOULD, KEVIN S (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:S
Last Name:MOULD
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 1:2330 W COVELL BLVD
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-5658
Mailing Address - Country:US
Mailing Address - Phone:530-756-2364
Mailing Address - Fax:
Practice Address - Street 1:2330 W COVELL BLVD
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-5658
Practice Address - Country:US
Practice Address - Phone:530-756-2364
Practice Address - Fax:530-756-5817
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA90920207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A909200Medicaid
CAP00284495OtherRR MEDICARE
CA00A909200OtherBLUE SHIELD
CA00A909200Medicaid