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General NPI Number Information
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NPI Number | 1346488004
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Entity Type | Organization
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Legal Business Name | COASTAL MEDICAL AND COSMETIC DERMATOLOGY INC
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Dates
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Enumeration Date | 02/03/2009
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Last Update Date | 12/17/2015
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Provider Practice Location Address
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Address Line | 9850 GENESEE AVE STE 500
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City | LA JOLLA
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State | CA
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Zip | 92037-1213
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Country | US
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Telephone | 858-657-0267
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Fax |
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Provider Business Mailing Address
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Address Line | 9850 GENESEE AVE STE 850
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City | LA JOLLA
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State | CA
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Zip | 92037-1213
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Country | US
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Telephone | 858-657-0267
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Fax |
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Authorized Official
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Title or Position | OWNER, PRESIDENT, CFO
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Name | DR. DARRELL WAYNE GONZALES
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Credential | M.D.
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Telephone | 858-657-0267
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | A88738
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License Number State | CA
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