Provider Demographics
NPI:1053422147
Name:COULOURES, KEVIN GOTTLIEB (DO)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:GOTTLIEB
Last Name:COULOURES
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:KEVIN
Other - Middle Name:GOTTLIEB
Other - Last Name:KETTLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO, MPH
Mailing Address - Street 1:725 WELCH RD
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94304-1601
Mailing Address - Country:US
Mailing Address - Phone:650-497-8000
Mailing Address - Fax:
Practice Address - Street 1:725 WELCH RD
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-1601
Practice Address - Country:US
Practice Address - Phone:650-497-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8013207R00000X, 208000000X, 2080P0203X, 2080P0203X
CT524872080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD413716700Medicaid
PA102040456Medicaid
NJ0147168Medicaid
MD413716700Medicaid