Provider Demographics
NPI:1730405879
Name:COASTAL DERMATOLOGY P.C.
Entity type:Organization
Organization Name:COASTAL DERMATOLOGY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:INGRAM SODERBERG
Authorized Official - Suffix:I
Authorized Official - Credentials:MD
Authorized Official - Phone:757-368-7546
Mailing Address - Street 1:3176 HOLLAND RD.
Mailing Address - Street 2:103
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23453
Mailing Address - Country:US
Mailing Address - Phone:757-368-7546
Mailing Address - Fax:
Practice Address - Street 1:3176 HOLLAND RD.
Practice Address - Street 2:103
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23453
Practice Address - Country:US
Practice Address - Phone:757-368-7546
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-14
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101241129207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty