Healthcare Provider Details

I. General information

NPI: 1699553552
Provider Name (Legal Business Name): COASTAL MEDICAL DERMATOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2023
Last Update Date: 09/20/2023
Certification Date: 09/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 W WIEUCA RD NE
ATLANTA GA
30342-3321
US

IV. Provider business mailing address

45 BOYNTON AVE SE UNIT 1207
ATLANTA GA
30315-1868
US

V. Phone/Fax

Practice location:
  • Phone: 215-439-9519
  • Fax: 678-647-6762
Mailing address:
  • Phone: 215-439-9519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: SANDRA V DAREUS
Title or Position: OWNER
Credential:
Phone: 215-439-9519