Provider Demographics
NPI:1336133966
Name:COFFIN, PAUL DOUGLAS (DPM)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:DOUGLAS
Last Name:COFFIN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3450 S LAKEPORT ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51106-4509
Mailing Address - Country:US
Mailing Address - Phone:712-255-5048
Mailing Address - Fax:712-255-5263
Practice Address - Street 1:3450 S LAKEPORT ST
Practice Address - Street 2:SUITE B
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51106-4509
Practice Address - Country:US
Practice Address - Phone:712-255-5048
Practice Address - Fax:712-255-5263
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-09
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA362213E00000X
NE275213E00000X
SD99213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1184655Medicaid
IAT01061Medicare UPIN
IA1184655Medicaid