Provider Demographics
NPI:1538169131
Name:COUCHENOUR, CORAL L (DO)
Entity type:Individual
Prefix:
First Name:CORAL
Middle Name:L
Last Name:COUCHENOUR
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 750
Mailing Address - Street 2:104 E. MAIN STREET
Mailing Address - City:ANDERSON
Mailing Address - State:MO
Mailing Address - Zip Code:64831-0750
Mailing Address - Country:US
Mailing Address - Phone:417-845-6984
Mailing Address - Fax:417-845-6976
Practice Address - Street 1:104 E. MAIN STREET
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:MO
Practice Address - Zip Code:64831-0750
Practice Address - Country:US
Practice Address - Phone:417-845-6984
Practice Address - Fax:417-845-6976
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-26
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2004017460207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207361601Medicaid
MO207361601Medicaid