Organization
COASTAL MEDICAL AND COSMETIC DERMATOLOGY INC
Active
Organization
COASTAL MEDICAL AND COSMETIC DERMATOLOGY INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. DARRELL WAYNE GONZALES M.D. (OWNER, PRESIDENT, CFO)
(858) 657-0267
Entity
Organization
Contact information
Practice address
9850 GENESEE AVE STE 500, LA JOLLA, CA 92037-1213
(858) 657-0267
Mailing address
9850 GENESEE AVE STE 850, LA JOLLA, CA 92037-1213
(858) 657-0267
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
A88738
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1417960188
INDIVIDUAL NPI
—
Enumeration date
02/03/2009
Last updated
12/17/2015
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