Provider Demographics
NPI:1376642082
Name:GULF COAST ASTHMA AND ALLERGY CLINIC
Entity Type:Organization
Organization Name:GULF COAST ASTHMA AND ALLERGY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:CLINTON
Authorized Official - Last Name:LEAVENGOOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-432-5955
Mailing Address - Street 1:1025 DIVISION ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39530-2906
Mailing Address - Country:US
Mailing Address - Phone:228-432-5955
Mailing Address - Fax:228-432-5952
Practice Address - Street 1:1025 DIVISION ST
Practice Address - Street 2:SUITE D
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39530-2906
Practice Address - Country:US
Practice Address - Phone:228-432-5955
Practice Address - Fax:228-432-5952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11243207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00110476Medicaid
MSBL1328182OtherDEA NUMBER
MS00110476Medicaid
MS512G700093Medicare PIN