MEDICARE: MR. MIKEL E COATES IDC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1710I1002X	Independent Duty Corpsman

General Provider Information

NPI Number	:	1215082862
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MIKEL E COATES IDC

Provider Business Mailing Address
First Line	:	617 SUHTAI CT APT 302
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23451-6074
Country	:	US
Telephone Number	:	301-592-7759
Fax Number	:

Provider Business Practice Location Address
First Line	:	1885 TERRIER AVE
Second Line	:	SUITE 100
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23461-2205
Country	:	US
Telephone Number	:	757-314-7200
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/24/2007
Last Update Date	:	07/08/2007

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