Provider Demographics
NPI:1912089061
Name:CRAIG, KEVIN L (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:L
Last Name:CRAIG
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 1:600 COFFEE RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-4201
Mailing Address - Country:US
Mailing Address - Phone:209-524-1211
Mailing Address - Fax:
Practice Address - Street 1:1011 SYLVAN AVE
Practice Address - Street 2:#C
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-1692
Practice Address - Country:US
Practice Address - Phone:209-550-4780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG80509207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G805090Medicaid
CAG00783Medicare UPIN
CA00G805090Medicaid