Provider Demographics
NPI:1922342229
Name:INTRACOASTAL PRIMARY HEALTH CARE, INC
Entity Type:Organization
Organization Name:INTRACOASTAL PRIMARY HEALTH CARE, INC
Other - Org Name:INTRACOASTAL PRIMARY HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VIJAY
Authorized Official - Middle Name:KUMAR
Authorized Official - Last Name:CHOWDHARY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-530-7515
Mailing Address - Street 1:935 INTRACOASTAL DR
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-3623
Mailing Address - Country:US
Mailing Address - Phone:954-530-7515
Mailing Address - Fax:
Practice Address - Street 1:935 INTRACOASTAL DR
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33304-3623
Practice Address - Country:US
Practice Address - Phone:954-530-7515
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-27
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME59508207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty