Provider Demographics
NPI:1003984493
Name:WYCHE T. COLEMAN, M.D., LIMITED
Entity Type:Organization
Organization Name:WYCHE T. COLEMAN, M.D., LIMITED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:WYCHE
Authorized Official - Middle Name:TAYLOR
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-932-9980
Mailing Address - Street 1:1633 MARVEL STREET
Mailing Address - Street 2:
Mailing Address - City:COUSHATTA
Mailing Address - State:LA
Mailing Address - Zip Code:71019
Mailing Address - Country:US
Mailing Address - Phone:318-932-9980
Mailing Address - Fax:318-932-9906
Practice Address - Street 1:1633 MARVEL STREET
Practice Address - Street 2:
Practice Address - City:COUSHATTA
Practice Address - State:LA
Practice Address - Zip Code:71019
Practice Address - Country:US
Practice Address - Phone:318-932-9980
Practice Address - Fax:318-932-9906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA015031207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1447994Medicaid
LA1447994Medicaid