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General NPI Number Information
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NPI Number | 1730405879
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Entity Type | Organization
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Legal Business Name | COASTAL DERMATOLOGY P.C.
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Dates
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Enumeration Date | 04/14/2010
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Last Update Date | 04/14/2010
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Provider Practice Location Address
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Address Line | 3176 HOLLAND RD. 103
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City | VIRGINIA BEACH
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State | VA
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Zip | 23453
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Country | US
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Telephone | 757-368-7546
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Fax |
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Provider Business Mailing Address
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Address Line | 3176 HOLLAND RD. 103
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City | VIRGINIA BEACH
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State | VA
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Zip | 23453
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Country | US
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Telephone | 757-368-7546
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KIMBERLY DIANE INGRAM SODERBERG I
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Credential | M.D.
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Telephone | 757-368-7546
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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 | 0101241129
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License Number State | VA
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