Provider Demographics
NPI:1912932054
Name:COYLE, DOUGLAS J (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:J
Last Name:COYLE
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 1:1789 SHAWANO AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-3243
Mailing Address - Country:US
Mailing Address - Phone:920-499-1428
Mailing Address - Fax:920-499-7080
Practice Address - Street 1:1789 SHAWANO AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303
Practice Address - Country:US
Practice Address - Phone:920-499-1428
Practice Address - Fax:920-499-5808
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI42438-0202085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4793122Medicaid
WI34468700Medicaid
4145510001OtherUNITED HEALTHCARE AMERICH
MI4793113Medicaid
14394OtherDEAN HEALTH
567565OtherDEAN HEALTH
P00252687Medicare Oscar/Certification
4145510001OtherUNITED HEALTHCARE AMERICH
MI4793122Medicaid
WI34468700Medicaid
14394OtherDEAN HEALTH
P00345946Medicare Oscar/Certification