Provider Demographics
NPI:1336319698
Name:COASTAL PODIATRY CLINIC
Entity Type:Organization
Organization Name:COASTAL PODIATRY CLINIC
Other - Org Name:COASTAL PODIATRY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:NORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:805-773-3668
Mailing Address - Street 1:2 JAMES WAY
Mailing Address - Street 2:SUITE 205
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-4973
Mailing Address - Country:US
Mailing Address - Phone:805-773-3668
Mailing Address - Fax:805-773-1043
Practice Address - Street 1:2 JAMES WAY
Practice Address - Street 2:SUITE 205
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-4973
Practice Address - Country:US
Practice Address - Phone:805-773-3668
Practice Address - Fax:805-773-1043
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RICHARD NORMAN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-03
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4306213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE4306OtherBOARD OF PODIATRIC MEDICINE LICENSE
CAE4306OtherBOARD OF PODIATRIC MEDICINE LICENSE
CA5082600001Medicare NSC