Provider Demographics
NPI:1578714440
Name:COUGHLIN, ANDREW M (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:M
Last Name:COUGHLIN
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 10190
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23450-0190
Mailing Address - Country:US
Mailing Address - Phone:800-477-5240
Mailing Address - Fax:757-463-6572
Practice Address - Street 1:8303 DODGE ST
Practice Address - Street 2:SUITE 304
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-4108
Practice Address - Country:US
Practice Address - Phone:402-354-5048
Practice Address - Fax:402-354-2585
Is Sole Proprietor?:No
Enumeration Date:2008-10-08
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE27214207Y00000X, 207YX0007X
TXBP10032053207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1578714440Medicaid
NE10026485711Medicaid
NE100250444-00Medicaid