Provider Demographics
NPI:1205812468
Name:COUGHLIN, BARRY JOHN (MD FACC)
Entity type:Individual
Prefix:
First Name:BARRY
Middle Name:JOHN
Last Name:COUGHLIN
Suffix:
Gender:M
Credentials:MD FACC
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 567
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93438
Mailing Address - Country:US
Mailing Address - Phone:805-736-1875
Mailing Address - Fax:805-735-9911
Practice Address - Street 1:136 NORTH THIRD ST STE 1
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436
Practice Address - Country:US
Practice Address - Phone:805-735-7771
Practice Address - Fax:805-735-9911
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-20
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC31374207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ38994ZOtherBLUE SHIELD OF CALIFORNIA
CA00C313740Medicaid
CAZZZ38994ZOtherBLUE SHIELD OF CALIFORNIA
A34551Medicare UPIN
CA00C313740Medicaid
CAHW12139Medicare PIN