Provider Demographics
NPI:1528193109
Name:COASTAL PEDIATRICS MEDICAL GROUP
Entity Type:Organization
Organization Name:COASTAL PEDIATRICS MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:BOHANNAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-983-3900
Mailing Address - Street 1:451 W GONZALES RD
Mailing Address - Street 2:STE 340
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93036-9004
Mailing Address - Country:US
Mailing Address - Phone:805-983-3900
Mailing Address - Fax:805-983-3887
Practice Address - Street 1:451 W GONZALES RD
Practice Address - Street 2:STE 340
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93036-9004
Practice Address - Country:US
Practice Address - Phone:805-983-3900
Practice Address - Fax:805-983-3887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ76023ZMedicaid