Healthcare Provider Details

I. General information

NPI: 1962664888
Provider Name (Legal Business Name): COASTAL CARDIOLOGY A MEDICAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2008
Last Update Date: 09/09/2025
Certification Date: 09/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1941 JOHNSON AVE STE 102
SAN LUIS OBISPO CA
93401-4154
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: 813-613-2633
Mailing address:
  • Phone: 805-782-8844
  • Fax: 805-540-5881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberA114658
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License Number
License Number State

VIII. Authorized Official

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