Provider Demographics
NPI:1316928377
Name:COATES-WYNN, GEOFFREY S (MD)
Entity type:Individual
Prefix:DR
First Name:GEOFFREY
Middle Name:S
Last Name:COATES-WYNN
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 1:1925 HOFFMEYER RD
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-4011
Mailing Address - Country:US
Mailing Address - Phone:843-679-4214
Mailing Address - Fax:843-679-4217
Practice Address - Street 1:1925 HOFFMEYER RD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-4011
Practice Address - Country:US
Practice Address - Phone:843-679-4214
Practice Address - Fax:843-679-4217
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2005-01611208100000X
SC24065208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5903120Medicaid
SCT84067Medicaid
SCT84067Medicaid