Provider Demographics
NPI:1790896264
Name:COAST TO COAST PODIATRY INC
Entity Type:Organization
Organization Name:COAST TO COAST PODIATRY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:DOMIS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:727-572-5449
Mailing Address - Street 1:PO BOX 56
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34682-0056
Mailing Address - Country:US
Mailing Address - Phone:727-572-5449
Mailing Address - Fax:278-445-4257
Practice Address - Street 1:905 E MARTIN LUTHER KING JR DR STE 320
Practice Address - Street 2:
Practice Address - City:TARPON SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34689-4853
Practice Address - Country:US
Practice Address - Phone:727-572-5449
Practice Address - Fax:727-573-2049
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COAST TO COAST PODIATRY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-31
Last Update Date:2021-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2713213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty