Provider Demographics
NPI:1598407926
Name:COUGHLIN, COLIN MATTHEW (MD)
Entity Type:Individual
Prefix:
First Name:COLIN
Middle Name:MATTHEW
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 1:4220 W 95TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-3072
Mailing Address - Country:US
Mailing Address - Phone:708-398-0287
Mailing Address - Fax:708-684-2032
Practice Address - Street 1:4220 W 95TH ST STE 200
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-3072
Practice Address - Country:US
Practice Address - Phone:708-398-0287
Practice Address - Fax:708-684-2032
Is Sole Proprietor?:No
Enumeration Date:2022-04-07
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.080267207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program