Provider Demographics
NPI:1396853941
Name:COASTAL UROLOGY P A
Entity Type:Organization
Organization Name:COASTAL UROLOGY P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:THUY
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-837-0442
Mailing Address - Street 1:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:SHALIMAR
Mailing Address - State:FL
Mailing Address - Zip Code:32579-0936
Mailing Address - Country:US
Mailing Address - Phone:850-837-0442
Mailing Address - Fax:850-837-1051
Practice Address - Street 1:4012 COMMONS DR W
Practice Address - Street 2:SUITE 100
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-8422
Practice Address - Country:US
Practice Address - Phone:850-837-0442
Practice Address - Fax:850-837-1051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME72919208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F92203Medicare UPIN
38090Medicare ID - Type Unspecified