Provider Demographics
NPI:1699553552
Name:COASTAL MEDICAL DERMATOLOGY
Entity type:Organization
Organization Name:COASTAL MEDICAL DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:V
Authorized Official - Last Name:DAREUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-439-9519
Mailing Address - Street 1:45 BOYNTON AVE SE UNIT 1207
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30315-1868
Mailing Address - Country:US
Mailing Address - Phone:215-439-9519
Mailing Address - Fax:
Practice Address - Street 1:285 W WIEUCA RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-3321
Practice Address - Country:US
Practice Address - Phone:215-439-9519
Practice Address - Fax:678-647-6762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-20
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty