Healthcare Provider Details

I. General information

NPI: 1740345271
Provider Name (Legal Business Name): DR. KEVIN COLDWATER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 11/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 NIELSON ST
WATSONVILLE CA
95076-2468
US

IV. Provider business mailing address

3220 GROSS RD
SANTA CRUZ CA
95062-2057
US

V. Phone/Fax

Practice location:
  • Phone: 831-728-0222
  • Fax:
Mailing address:
  • Phone: 831-406-7656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A11364
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: