Provider Demographics
NPI:1013969260
Name:COASTAL ORTHOPAEDICS AND SPORTS
Entity Type:Organization
Organization Name:COASTAL ORTHOPAEDICS AND SPORTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:CANDELORA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-848-1417
Mailing Address - Street 1:5145 DEER PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34653
Mailing Address - Country:US
Mailing Address - Phone:727-848-1417
Mailing Address - Fax:727-847-7526
Practice Address - Street 1:5145 DEER PARK DR
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34653-7013
Practice Address - Country:US
Practice Address - Phone:727-848-1417
Practice Address - Fax:727-847-7526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CD6290OtherRAILROAD MEDICARE
6043500001Medicare NSC
FL33950Medicare ID - Type Unspecified