Provider Demographics
NPI:1750727749
Name:COUGHLIN, KEVIN A (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:A
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 1:9 MEDFORD ST APT 413
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-4252
Mailing Address - Country:US
Mailing Address - Phone:413-244-4513
Mailing Address - Fax:
Practice Address - Street 1:1493 CAMBRIDGE ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139
Practice Address - Country:US
Practice Address - Phone:617-665-3267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-16
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2666462084P0804X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program