Provider Demographics
NPI:1285683086
Name:COGHLAN, RAYMOND A (MD)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:A
Last Name:COGHLAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2551 GREENWOOD RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3981
Mailing Address - Country:US
Mailing Address - Phone:318-631-9996
Mailing Address - Fax:318-631-9345
Practice Address - Street 1:2551 GREENWOOD RD
Practice Address - Street 2:SUITE 150
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3981
Practice Address - Country:US
Practice Address - Phone:318-631-9996
Practice Address - Fax:318-631-9345
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA018860207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1384003Medicaid
LA52318CX64Medicare PIN
LA52318Medicare PIN
B89524Medicare UPIN