Provider Demographics
NPI:1417150236
Name:COASTAL UROLOGY PLLC
Entity Type:Organization
Organization Name:COASTAL UROLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:ELIAS
Authorized Official - Last Name:ABRAHAM
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:910-254-9995
Mailing Address - Street 1:1099 MEDICAL CENTER DR
Mailing Address - Street 2:STE 101
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7367
Mailing Address - Country:US
Mailing Address - Phone:910-254-9995
Mailing Address - Fax:910-254-9996
Practice Address - Street 1:1099 MEDICAL CENTER DR
Practice Address - Street 2:STE 101
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7367
Practice Address - Country:US
Practice Address - Phone:910-254-9995
Practice Address - Fax:910-254-9996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-08
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9700005208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC232129Medicare PIN