Provider Demographics
NPI:1154455541
Name:COAST ORTHOPEDIC SPECIALTY ASSOCIATES
Entity Type:Organization
Organization Name:COAST ORTHOPEDIC SPECIALTY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:G
Authorized Official - Last Name:KOWALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-466-2333
Mailing Address - Street 1:78 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TEMPLETON
Mailing Address - State:CA
Mailing Address - Zip Code:93465-9787
Mailing Address - Country:US
Mailing Address - Phone:805-434-0999
Mailing Address - Fax:805-434-5267
Practice Address - Street 1:78 S MAIN ST
Practice Address - Street 2:
Practice Address - City:TEMPLETON
Practice Address - State:CA
Practice Address - Zip Code:93465-9787
Practice Address - Country:US
Practice Address - Phone:805-434-0999
Practice Address - Fax:805-434-5267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG074354207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF36353Medicare UPIN
CAF15872Medicare UPIN