Provider Demographics
NPI:1679459077
Name:PACIFIC COASTAL MEDICAL GROUP PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:PACIFIC COASTAL MEDICAL GROUP PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:OLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-290-4309
Mailing Address - Street 1:2604B EL CAMINO REAL UNIT 340
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-1214
Mailing Address - Country:US
Mailing Address - Phone:760-290-4309
Mailing Address - Fax:
Practice Address - Street 1:960 W SAN MARCOS BLVD STE 210
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92078-1147
Practice Address - Country:US
Practice Address - Phone:760-290-4309
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-12
Last Update Date:2025-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty