Healthcare Provider Details

I. General information

NPI: 1710235569
Provider Name (Legal Business Name): WEST COAST PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2012
Last Update Date: 02/07/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 59TH STREET WEST
BRADENTON FL
34209-4607
US

IV. Provider business mailing address

1414 59TH STREET WEST
BRADENTON FL
34209-4607
US

V. Phone/Fax

Practice location:
  • Phone: 941-761-0663
  • Fax: 941-761-3347
Mailing address:
  • Phone: 941-761-0663
  • Fax: 941-761-3347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: CONSTANCE CHARLES-LOGAN
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 941-761-0663