Healthcare Provider Details

I. General information

NPI: 1619127693
Provider Name (Legal Business Name): COASTAL CARDIOLOGY A MEDICAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2008
Last Update Date: 09/09/2025
Certification Date: 09/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 S HALCYON RD
ARROYO GRANDE CA
93420
US

IV. Provider business mailing address

PO BOX 12003
SAN LUIS OBISPO CA
93406-2003
US

V. Phone/Fax

Practice location:
  • Phone: 805-782-8844
  • Fax:
Mailing address:
  • Phone: 805-782-8844
  • Fax: 805-540-5881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: MARISSA FAMULARO
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 805-782-8844