Provider Demographics
NPI:1619127693
Name:COASTAL CARDIOLOGY A MEDICAL CORP
Entity type:Organization
Organization Name:COASTAL CARDIOLOGY A MEDICAL CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:FAMULARO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-782-8844
Mailing Address - Street 1:PO BOX 12003
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93406-2003
Mailing Address - Country:US
Mailing Address - Phone:805-782-8844
Mailing Address - Fax:805-540-5881
Practice Address - Street 1:345 S HALCYON RD
Practice Address - Street 2:
Practice Address - City:ARROYO GRANDE
Practice Address - State:CA
Practice Address - Zip Code:93420
Practice Address - Country:US
Practice Address - Phone:805-782-8844
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-25
Last Update Date:2025-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ24859ZOtherBLUE SHIELD
CP1074OtherRR MEDICARE
CAGR0068680Medicaid
CAWG58530EMedicare PIN
CAWG23388AMedicare PIN
CAWA63687BMedicare PIN
CAWA54052HMedicare PIN
CAWG69997GMedicare PIN
CAWG21420EMedicare PIN
CAWG56853HMedicare PIN
CAZZZ24859ZOtherBLUE SHIELD
CAWG29696AMedicare PIN
CP1074OtherRR MEDICARE
CAWG54180BMedicare PIN