Healthcare Provider Details

I. General information

NPI: 1164560066
Provider Name (Legal Business Name): COASTAL EYE ASSOCIATES, A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 07/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 GREEN VALLEY RD SUITE 202
FREEDOM CA
95019-3160
US

IV. Provider business mailing address

160 GREEN VALLEY RD SUITE 202
FREEDOM CA
95019-3160
US

V. Phone/Fax

Practice location:
  • Phone: 831-728-2020
  • Fax: 831-728-4739
Mailing address:
  • Phone: 831-728-2020
  • Fax: 831-728-4739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberFNP24052
License Number StateCA

VIII. Authorized Official

Name: DR. CONRAD K HAMAKO
Title or Position: PRESIDENT
Credential: MD
Phone: 831-728-2020