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General NPI Number Information
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NPI Number | 1952525859
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Entity Type | Organization
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Legal Business Name | COASTLINE MEDICAL CENTER, PLLC
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Dates
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Enumeration Date | 04/12/2007
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Last Update Date | 01/04/2011
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Provider Practice Location Address
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Address Line | 10536 AUTO MALL PKWY SUITE A
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City | DIBERVILLE
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State | MS
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Zip | 39540-3742
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Country | US
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Telephone | 228-396-0333
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Fax | 228-396-4060
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Provider Business Mailing Address
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Address Line | 10536 AUTO MALL PKWY A
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City | DIBERVILLE
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State | MS
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Zip | 39540-3742
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Country | US
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Telephone | 228-396-0333
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Fax | 228-396-4060
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. NGUYEN PHONG HUYNH
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Credential | D.O
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Telephone | 228-396-0333
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 19050
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 19541
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License Number State | MS
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