Provider Demographics
NPI:1891873139
Name:COASTAL EYE SPECIALISTS MEDICAL GROUP INC
Entity Type:Organization
Organization Name:COASTAL EYE SPECIALISTS MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:W
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-983-0700
Mailing Address - Street 1:1700 N ROSE AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93030
Mailing Address - Country:US
Mailing Address - Phone:805-983-0700
Mailing Address - Fax:805-983-7492
Practice Address - Street 1:1700 N ROSE AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93030
Practice Address - Country:US
Practice Address - Phone:805-983-0700
Practice Address - Fax:805-983-7492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALIAOOD OPT115TPA152W00000X
CAG50251207W00000X
CAA92760207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Not Answered207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0076240Medicaid
CAW14516Medicare ID - Type Unspecified
CAGR0076240Medicaid
U98310Medicare UPIN
I44229Medicare UPIN