Healthcare Provider Details

I. General information

NPI: 1215082862
Provider Name (Legal Business Name): MIKEL E COATES IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1885 TERRIER AVE SUITE 100
VIRGINIA BEACH VA
23461-2205
US

IV. Provider business mailing address

617 SUHTAI CT APT 302
VIRGINIA BEACH VA
23451-6074
US

V. Phone/Fax

Practice location:
  • Phone: 757-314-7200
  • Fax:
Mailing address:
  • Phone: 301-592-7759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: