Healthcare Provider Details

I. General information

NPI: 1346488004
Provider Name (Legal Business Name): COASTAL MEDICAL AND COSMETIC DERMATOLOGY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2009
Last Update Date: 12/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9850 GENESEE AVE STE 500
LA JOLLA CA
92037-1213
US

IV. Provider business mailing address

9850 GENESEE AVE STE 850
LA JOLLA CA
92037-1213
US

V. Phone/Fax

Practice location:
  • Phone: 858-657-0267
  • Fax:
Mailing address:
  • Phone: 858-657-0267
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA88738
License Number StateCA

VIII. Authorized Official

Name: DR. DARRELL WAYNE GONZALES
Title or Position: OWNER, PRESIDENT, CFO
Credential: M.D.
Phone: 858-657-0267