Provider Demographics
NPI:1104251230
Name:COASTAL HEART & VASCULAR INSTITUTE PA
Entity type:Organization
Organization Name:COASTAL HEART & VASCULAR INSTITUTE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:MARITZA
Authorized Official - Last Name:JARA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-963-3943
Mailing Address - Street 1:2500 BOBCAT VILLAGE CENTER RD
Mailing Address - Street 2:UNIT G
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34288-8476
Mailing Address - Country:US
Mailing Address - Phone:407-963-3943
Mailing Address - Fax:407-400-7966
Practice Address - Street 1:2500 BOBCAT VILLAGE CENTER RD
Practice Address - Street 2:UNIT G
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34288-8476
Practice Address - Country:US
Practice Address - Phone:407-963-3943
Practice Address - Fax:407-400-7966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-09
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty