Provider Demographics
NPI:1356569834
Name:NORTH COAST FAMILY MEDICAL GROUP
Entity type:Organization
Organization Name:NORTH COAST FAMILY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:S
Authorized Official - Last Name:DUCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-942-0118
Mailing Address - Street 1:477 N. EL CAMINO REAL
Mailing Address - Street 2:A306
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-1350
Mailing Address - Country:US
Mailing Address - Phone:760-942-0118
Mailing Address - Fax:760-942-5319
Practice Address - Street 1:477 N. EL CAMINO REAL
Practice Address - Street 2:A306
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-1350
Practice Address - Country:US
Practice Address - Phone:760-942-0118
Practice Address - Fax:760-942-5319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG50467208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW13521Medicare ID - Type UnspecifiedGROUP PROVIDER #