Healthcare Provider Details

I. General information

NPI: 1972530194
Provider Name (Legal Business Name): THOMAS J. COGHLIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 09/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 VILLAGE SQUARE DRIVE BUILDING 24
SOUTH KINGSTOWN RI
02879
US

IV. Provider business mailing address

150 EAST MANNING STREET
PROVIDENCE RI
02906
US

V. Phone/Fax

Practice location:
  • Phone: 401-272-2020
  • Fax: 401-789-4113
Mailing address:
  • Phone: 401-272-2020
  • Fax: 401-421-5979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number30866
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: