Healthcare Provider Details

I. General information

NPI: 1114238193
Provider Name (Legal Business Name): COASTAL SKIN SURGERY AND DERMATOLOGY, PL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2010
Last Update Date: 04/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12469 EMERALD COAST PKWY W SUITE 101
MIRAMAR BEACH FL
32550-8305
US

IV. Provider business mailing address

12469 EMERALD COAST PKWY W SUITE 101
MIRAMAR BEACH FL
32550-8305
US

V. Phone/Fax

Practice location:
  • Phone: 850-654-3376
  • Fax: 850-654-3320
Mailing address:
  • Phone: 850-654-3376
  • Fax: 850-654-3320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberME92098
License Number StateFL

VIII. Authorized Official

Name: DAVID C ADAMS
Title or Position: OWNER, PRESIDENT
Credential: MD
Phone: 850-654-3376