=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699553552
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COASTAL MEDICAL DERMATOLOGY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2023
-----------------------------------------------------
Last Update Date | 09/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 285 W WIEUCA RD NE
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30342-3321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-439-9519
-----------------------------------------------------
Fax | 678-647-6762
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 45 BOYNTON AVE SE UNIT 1207
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30315-1868
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-439-9519
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SANDRA V DAREUS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 215-439-9519
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------