Provider Demographics
NPI:1992139117
Name:GOULD, KEVIN TIDWELL (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:TIDWELL
Last Name:GOULD
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 1:374TH MEDICAL GROUP
Mailing Address - Street 2:UNIT 5071
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96328-5071
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:374TH MEDICAL GROUP
Practice Address - Street 2:UNIT 5071
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96328-5071
Practice Address - Country:US
Practice Address - Phone:425-381-0707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-23
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61062122207P00000X
VA0101257209207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARES000Medicare UPIN