Healthcare Provider Details

I. General information

NPI: 1124477211
Provider Name (Legal Business Name): MICHAEL JACK COULTER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2016
Last Update Date: 08/23/2022
Certification Date: 08/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MERCY CIRCLE
CAMP PENDLETON CA
92055
US

IV. Provider business mailing address

PO BOX 555191
CAMP PENDLETON CA
92055-5191
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-6646
  • Fax:
Mailing address:
  • Phone: 760-725-6646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberA150427
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberD7935901
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: