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General NPI Number Information
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NPI Number | 1790896264
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Entity Type | Organization
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Legal Business Name | COAST TO COAST PODIATRY INC
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Dates
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Enumeration Date | 08/31/2006
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Last Update Date | 03/21/2021
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Provider Practice Location Address
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Address Line | 905 E MARTIN LUTHER KING JR DR STE 320
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City | TARPON SPRINGS
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State | FL
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Zip | 34689-4853
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Country | US
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Telephone | 727-572-5449
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Fax | 727-573-2049
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Provider Business Mailing Address
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Address Line | PO BOX 56
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City | PALM HARBOR
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State | FL
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Zip | 34682-0056
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Country | US
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Telephone | 727-572-5449
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Fax | 278-445-4257
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MICHAEL E DOMIS
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Credential | DPM
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Telephone | 727-572-5449
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | PO2713
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License Number State | FL
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