Provider Demographics
NPI:1366431769
Name:COASTAL DERMATOLOGY PA
Entity type:Organization
Organization Name:COASTAL DERMATOLOGY PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SANJIVA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOYAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-567-1050
Mailing Address - Street 1:PO BOX 2878
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32004-2878
Mailing Address - Country:US
Mailing Address - Phone:904-567-1050
Mailing Address - Fax:904-567-1051
Practice Address - Street 1:2804 SAINT JOHNS BLUFF RD S
Practice Address - Street 2:STE 109
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-3776
Practice Address - Country:US
Practice Address - Phone:904-727-9123
Practice Address - Fax:904-855-4255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-18
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL35493ZOtherMEDICARE PROVIDER ID
FLK3994OtherMEDICARE PTAN
FLK3994OtherMEDICARE PTAN