Provider Demographics
NPI:1124424098
Name:COASTAL PHYSICIAN CARE LLC
Entity type:Organization
Organization Name:COASTAL PHYSICIAN CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:L
Authorized Official - Last Name:DARSTEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-898-3836
Mailing Address - Street 1:1865 VETERANS PARK DR STE 202
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34109-0447
Mailing Address - Country:US
Mailing Address - Phone:239-898-3836
Mailing Address - Fax:
Practice Address - Street 1:9250 CORKSCREW RD
Practice Address - Street 2:SUITE 3
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:33928-3208
Practice Address - Country:US
Practice Address - Phone:239-498-2528
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-05
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent MedicineGroup - Multi-Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty