Provider Demographics
NPI:1932408622
Name:COUGHLIN, LISA MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:MARIE
Last Name:COUGHLIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 N SUMMIT ST FL 7
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-1531
Mailing Address - Country:US
Mailing Address - Phone:419-693-0711
Mailing Address - Fax:419-693-2320
Practice Address - Street 1:2751 BAY PARK DR STE 300-303
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:OH
Practice Address - Zip Code:43616
Practice Address - Country:US
Practice Address - Phone:419-693-0711
Practice Address - Fax:419-693-2320
Is Sole Proprietor?:No
Enumeration Date:2011-03-21
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD465786208600000X
OH35-120363208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0084903Medicaid
PAPENDINGMedicaid
PAPENDINGOtherMEDICARE