Provider Demographics
NPI:1821180621
Name:GOLD COAST PULMONARY AND SLEEP ASSOCIATES, LLC
Entity Type:Organization
Organization Name:GOLD COAST PULMONARY AND SLEEP ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:JUSTIN
Authorized Official - Last Name:LICATA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:860-443-0305
Mailing Address - Street 1:492 MONTAUK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-4615
Mailing Address - Country:US
Mailing Address - Phone:860-443-0305
Mailing Address - Fax:860-444-0823
Practice Address - Street 1:492 MONTAUK AVE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4615
Practice Address - Country:US
Practice Address - Phone:860-443-0305
Practice Address - Fax:860-444-0823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000413207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT50GOLDCOACT01OtherANTHEM GROUP NUMBER
CT50GOLDCOACT01OtherANTHEM GROUP NUMBER
CTC02829Medicare PIN