Organization
COASTAL CARDIOLOGY A MEDICAL CORP
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MARISSA FAMULARO (OPERATIONS MANAGER)
(805) 782-8844
Entity
Organization
Contact information
Practice address
1941 JOHNSON AVE STE 102, SAN LUIS OBISPO, CA 93401-4154
(805) 782-8844
(813) 613-2633
Mailing address
PO BOX 12003, SAN LUIS OBISPO, CA 93406-2003
(805) 782-8844
(805) 540-5881
Taxonomy
Speciality
Code
Description
License number
State
207RC0000X
Cardiovascular Disease Physician
Primary
—
—
207RI0011X
Interventional Cardiology Physician
A114658
CA
207U00000X
Nuclear Medicine Physician
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
CP1074
RR MEDICARE
CA
05
—
GR000068680
—
CA
01
—
ZZZ28458Z
BLUE SHIELD
CA
Enumeration date
07/01/2008
Last updated
09/09/2025
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