Provider Demographics
NPI:1811912793
Name:COASTAL FAMILY MEDICINE ASSOCIATES, PA
Entity type:Organization
Organization Name:COASTAL FAMILY MEDICINE ASSOCIATES, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:D
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:361-857-0178
Mailing Address - Street 1:PO BOX 271626
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78427
Mailing Address - Country:US
Mailing Address - Phone:361-857-0178
Mailing Address - Fax:361-855-4123
Practice Address - Street 1:3817 S PADRE ISLAND DRIVE
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78415
Practice Address - Country:US
Practice Address - Phone:361-857-0178
Practice Address - Fax:361-855-4123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8607207Q00000X
TXG7647207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00941RMedicare ID - Type Unspecified
B22860Medicare UPIN
G17178Medicare UPIN