MEDICARE: COASTAL CARDIOLOGY A MEDICAL CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA23186	CA
2	207RI0011X	Interventional Cardiology Physician	A114658	CA
3	207RC0000X	Cardiovascular Disease Physician		CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	ZZZ24859Z	OTHER	CA	BLUE SHIELD

General Provider Information

NPI Number	:	1578725495
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL CARDIOLOGY A MEDICAL CORP

Provider Business Mailing Address
First Line	:	PO BOX 12003
Second Line	:
City	:	SAN LUIS OBISPO
State	:	CA
Zip	:	93406-2003
Country	:	US
Telephone Number	:	805-782-8844
Fax Number	:	805-540-5881

Provider Business Practice Location Address
First Line	:	310 SOUTH HALCYON ROAD STE 105
Second Line	:
City	:	ARROYO GRANDE
State	:	CA
Zip	:	93420-3872
Country	:	US
Telephone Number	:	805-782-8844
Fax Number	:	813-613-2632

Authorized Official
Title or Position	:	OPERATIONS MANAGER
Name	:	MARISSA FAMULARO
Credential	:
Telephone Number	:	805-782-8844

Provider Enumeration Date	:	07/01/2008
Last Update Date	:	09/09/2025

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Directions to “COASTAL CARDIOLOGY A MEDICAL CORP ” Practice Location

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