Healthcare Provider Details

I. General information

NPI: 1588845978
Provider Name (Legal Business Name): COASTAL PHYSICIANS MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2007
Last Update Date: 11/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

824 E CARSON ST STE 101
CARSON CA
90745-2262
US

IV. Provider business mailing address

824 E CARSON ST STE 101
CARSON CA
90745-2262
US

V. Phone/Fax

Practice location:
  • Phone: 310-233-3202
  • Fax: 310-233-3208
Mailing address:
  • Phone: 310-233-3202
  • Fax: 310-233-3208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. LUIS G MAGDALENO
Title or Position: CEO
Credential: M.D.
Phone: 310-832-4225