Provider Demographics
NPI:1932131158
Name:COASTAL RADIATION ONCOLOGY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:COASTAL RADIATION ONCOLOGY MEDICAL GROUP, INC.
Other - Org Name:COASTAL RADIATION ONCOLOGY MEDICAL GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:M
Authorized Official - Last Name:RODNICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-648-5191
Mailing Address - Street 1:100 CASA ST STE C
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-8804
Mailing Address - Country:US
Mailing Address - Phone:805-541-1932
Mailing Address - Fax:805-541-1653
Practice Address - Street 1:2985 SYCAMORE DR
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-1201
Practice Address - Country:US
Practice Address - Phone:805-584-6611
Practice Address - Fax:805-584-0530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0047642Medicaid
W19778Medicare PIN