Provider Demographics
NPI:1427195874
Name:COASTAL FOOT AND ANKLE, LLC
Entity Type:Organization
Organization Name:COASTAL FOOT AND ANKLE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:D.P.M.
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:M
Authorized Official - Last Name:MENENDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:302-644-8500
Mailing Address - Street 1:33759 CLAY RD UNIT 2
Mailing Address - Street 2:
Mailing Address - City:LEWES
Mailing Address - State:DE
Mailing Address - Zip Code:19958-6294
Mailing Address - Country:US
Mailing Address - Phone:302-644-8500
Mailing Address - Fax:302-644-7355
Practice Address - Street 1:33759 CLAY RD UNIT 2
Practice Address - Street 2:
Practice Address - City:LEWES
Practice Address - State:DE
Practice Address - Zip Code:19958-6294
Practice Address - Country:US
Practice Address - Phone:302-644-8500
Practice Address - Fax:302-644-7355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEE10000140213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEU75310Medicare UPIN
DE5118690002Medicare NSC
DEG01077Medicare PIN