Provider Demographics
NPI:1568438323
Name:COUGHRAN, JIMMY R (MD)
Entity Type:Individual
Prefix:DR
First Name:JIMMY
Middle Name:R
Last Name:COUGHRAN
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:PO BOX 730
Mailing Address - Street 2:
Mailing Address - City:WINNSBORO
Mailing Address - State:LA
Mailing Address - Zip Code:71295-0730
Mailing Address - Country:US
Mailing Address - Phone:318-435-8020
Mailing Address - Fax:318-435-8099
Practice Address - Street 1:101 FAIR AVENUE
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:LA
Practice Address - Zip Code:71295-2116
Practice Address - Country:US
Practice Address - Phone:318-435-8020
Practice Address - Fax:318-435-8099
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-23
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA021579207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAL92023OtherVANTAGE PROVIDER
LA1449130Medicaid
LA5287021OtherAETNA PROVIDER NUMBER
LA1971391Medicaid
LA5CN24Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER
LA1971391Medicaid
LA1449130Medicaid
LA080140677Medicare ID - Type UnspecifiedRAILROAD MEDICARE