Provider Demographics
NPI:1962664888
Name:COASTAL CARDIOLOGY A MEDICAL CORP
Entity type:Organization
Organization Name:COASTAL CARDIOLOGY A MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:FAMULARO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-782-8844
Mailing Address - Street 1:PO BOX 12003
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93406-2003
Mailing Address - Country:US
Mailing Address - Phone:805-782-8844
Mailing Address - Fax:805-540-5881
Practice Address - Street 1:1941 JOHNSON AVE STE 102
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4154
Practice Address - Country:US
Practice Address - Phone:805-782-8844
Practice Address - Fax:813-613-2633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-01
Last Update Date:2025-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207U00000X, 207RC0000X, 207U00000X, 207RC0000X
CAA114658207RI0011X, 207RI0011X
CAG56853207RC0000X
CAA116056207RC0000X
CAG44009207RC0000X
CAC128646207RC0001X
CAA63687207RI0011X
CAG54180207RI0011X
CAG29696207RI0011X
CAG69997207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207U00000XAllopathic & Osteopathic PhysiciansNuclear MedicineGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac ElectrophysiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR000068680Medicaid
CACP1074OtherRR MEDICARE
CAZZZ28458ZOtherBLUE SHIELD
CAWG54180MMedicare PIN
CAWG69997OMedicare PIN
CAZZZ28458ZOtherBLUE SHIELD
CACP1074OtherRR MEDICARE
CAWA63687IMedicare PIN
CAWG29073MMedicare PIN
CAWA54052MMedicare PIN
CAWG56853MMedicare PIN
CAWG21420CMedicare PIN
CAWG44009KMedicare PIN
CAWG5853OJMedicare PIN