Provider Demographics
NPI:1346488004
Name:COASTAL MEDICAL AND COSMETIC DERMATOLOGY INC
Entity Type:Organization
Organization Name:COASTAL MEDICAL AND COSMETIC DERMATOLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PRESIDENT, CFO
Authorized Official - Prefix:DR
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-657-0267
Mailing Address - Street 1:9850 GENESEE AVE STE 850
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1213
Mailing Address - Country:US
Mailing Address - Phone:858-657-0267
Mailing Address - Fax:
Practice Address - Street 1:9850 GENESEE AVE STE 500
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1213
Practice Address - Country:US
Practice Address - Phone:858-657-0267
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-03
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA88738207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1417960188OtherINDIVIDUAL NPI
1417960188OtherINDIVIDUAL NPI