Provider Demographics
NPI:1114238193
Name:COASTAL SKIN SURGERY AND DERMATOLOGY, PL
Entity Type:Organization
Organization Name:COASTAL SKIN SURGERY AND DERMATOLOGY, PL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:C
Authorized Official - Last Name:ADAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-654-3376
Mailing Address - Street 1:12469 EMERALD COAST PKWY W
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MIRAMAR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32550-8305
Mailing Address - Country:US
Mailing Address - Phone:850-654-3376
Mailing Address - Fax:850-654-3320
Practice Address - Street 1:12469 EMERALD COAST PKWY W
Practice Address - Street 2:SUITE 101
Practice Address - City:MIRAMAR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32550-8305
Practice Address - Country:US
Practice Address - Phone:850-654-3376
Practice Address - Fax:850-654-3320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-24
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207N00000X
FLME92098207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL00175OtherBCBSFL
FLDP316AMedicare PIN