NPIMap

Organization Active NPI

Coastal Dermatology PA

  • Dermatology Physician
  • Jacksonville, FL
National Provider Identifier
1366431769
Registry record updated May 8, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 207N00000X
Legal business name
COASTAL DERMATOLOGY PA
Practice address
2804 Saint Johns Bluff Rd S
Ste 109
Jacksonville, FL 32246-3776
Phone
(904) 727-9123
Fax
(904) 855-4255
NPI assigned
Oct 18, 2005
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 8, 2015

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Sanjiva Goyal, M.D.NPI 1558350702
Title
President
Phone
(904) 567-1050

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatology PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207N00000X Primary

Addresses

Primary practice location

2804 Saint Johns Bluff Rd S
Ste 109
Jacksonville, FL 32246-3776

Mailing address

PO Box 2878
Ponte Vedra Beach, FL 32004-2878
Phone (904) 567-1050

Other identifiers 2

IdentifierTypeStateIssuer
35493ZOtherFLMEDICARE PROVIDER ID
K3994OtherFLMEDICARE PTAN

Other names 1

  • Goyal Dermatology Inc Former legal business name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20050126000366 FL Part B Supplier - Clinic/Group Practice 2961452107 Receives reassigned benefits from 8 practitioners
Practice locations: Jacksonville, FL; Ponte Vedra Beach, FL

National Provider Directory

National Provider Directory

Locations

2804 Saint Johns Bluff Rd S
Jacksonville, FL 32246
Phone (904) 493-1005

1205 Monument Rd
Ste 303
Jacksonville, FL 32225
Phone (904) 727-9123

183 Landrum Ln
Ponte Vedra Beach, FL 32082

Practitioners & affiliated clinicians

Practitioners 11

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1129593600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1431043200000",
    "number": "1366431769",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 2878",
            "city": "PONTE VEDRA BEACH",
            "state": "FL",
            "postal_code": "320042878",
            "telephone_number": "904-567-1050",
            "fax_number": "904-567-1051"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2804 SAINT JOHNS BLUFF RD S",
            "address_2": "STE 109",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "322463776",
            "telephone_number": "904-727-9123",
            "fax_number": "904-855-4255"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COASTAL DERMATOLOGY PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-10-18",
        "last_updated": "2015-05-08",
        "status": "A",
        "authorized_official_last_name": "GOYAL",
        "authorized_official_first_name": "SANJIVA",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "904-567-1050",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Dermatology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PROVIDER ID",
            "identifier": "35493Z",
            "state": "FL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PTAN",
            "identifier": "K3994",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Goyal Dermatology Inc",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Jacksonville, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 8, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.