Healthcare Provider Details

I. General information

NPI: 1164283180
Provider Name (Legal Business Name): COASTLINE PEDIATRIC CARDIOLOGY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2024
Last Update Date: 01/17/2024
Certification Date: 01/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4425 JAMBOREE RD STE 129
NEWPORT BEACH CA
92660-3002
US

IV. Provider business mailing address

1401 21ST ST STE R
SACRAMENTO CA
95811-5226
US

V. Phone/Fax

Practice location:
  • Phone: 914-262-3351
  • Fax:
Mailing address:
  • Phone: 914-262-3351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JUSTIN PICK
Title or Position: CHIEF MEDICAL OFFICER
Credential: MD
Phone: 914-262-3351