Provider Demographics
NPI:1306092549
Name:COASTAL MOBILE MEDICAL DOCTOR, PA
Entity type:Organization
Organization Name:COASTAL MOBILE MEDICAL DOCTOR, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:NARENDER
Authorized Official - Middle Name:DEIVASEKHAMANI
Authorized Official - Last Name:ARCOT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-355-6696
Mailing Address - Street 1:203 STAGECOACH DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-9617
Mailing Address - Country:US
Mailing Address - Phone:910-355-6696
Mailing Address - Fax:
Practice Address - Street 1:203 STAGECOACH DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-9617
Practice Address - Country:US
Practice Address - Phone:910-355-6696
Practice Address - Fax:910-355-6696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-07
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200100829207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2292281DMedicare PIN