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General NPI Number Information
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NPI Number | 1366431769
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Entity Type | Organization
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Legal Business Name | COASTAL DERMATOLOGY PA
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Dates
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Enumeration Date | 10/18/2005
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Last Update Date | 05/08/2015
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Provider Practice Location Address
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Address Line | 2804 SAINT JOHNS BLUFF RD S STE 109
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City | JACKSONVILLE
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State | FL
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Zip | 32246-3776
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Country | US
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Telephone | 904-727-9123
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Fax | 904-855-4255
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Provider Business Mailing Address
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Address Line | PO BOX 2878
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City | PONTE VEDRA BEACH
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State | FL
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Zip | 32004-2878
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Country | US
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Telephone | 904-567-1050
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Fax | 904-567-1051
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Authorized Official
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Title or Position | PRESIDENT
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Name | SANJIVA GOYAL
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Credential | M.D.
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Telephone | 904-567-1050
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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 |
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License Number State |
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