Provider Demographics
NPI:1265855506
Name:CROWN ISLAND FAMILY PRACTICE A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:CROWN ISLAND FAMILY PRACTICE A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CONSIDINE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:619-537-6910
Mailing Address - Street 1:230 PROSPECT PL
Mailing Address - Street 2:SUITE 350
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118-1978
Mailing Address - Country:US
Mailing Address - Phone:619-537-6910
Mailing Address - Fax:619-537-6905
Practice Address - Street 1:230 PROSPECT PL
Practice Address - Street 2:SUITE 350
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118-1978
Practice Address - Country:US
Practice Address - Phone:619-537-6910
Practice Address - Fax:619-537-6905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-22
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6446207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF97741Medicare UPIN