Provider Demographics
NPI:1346427143
Name:FIRST COAST ENT
Entity Type:Organization
Organization Name:FIRST COAST ENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:TEMPLE
Authorized Official - Last Name:FRAKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-729-2794
Mailing Address - Street 1:2040 DAN PROCTOR DR
Mailing Address - Street 2:SUITE 250
Mailing Address - City:SAINT MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558-3811
Mailing Address - Country:US
Mailing Address - Phone:912-729-2794
Mailing Address - Fax:912-729-4469
Practice Address - Street 1:2040 DAN PROCTOR DR
Practice Address - Street 2:SUITE 250
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-3811
Practice Address - Country:US
Practice Address - Phone:912-729-2794
Practice Address - Fax:912-729-4469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-24
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056552174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7383Medicare PIN