Healthcare Provider Details

I. General information

NPI: 1104457159
Provider Name (Legal Business Name): GERARD JOHN-CHARLES COUGHLIN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2020
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1802 BRAEBURN DR STE A2130
SALEM VA
24153-7357
US

IV. Provider business mailing address

PO BOX 825159
PHILADELPHIA PA
19182-5159
US

V. Phone/Fax

Practice location:
  • Phone: 540-344-3668
  • Fax:
Mailing address:
  • Phone: 866-626-1540
  • Fax: 866-386-8526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number0103301473
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: