Provider Demographics
NPI:1053492710
Name:COLEMAN, CLIFFORD LOREN (MD)
Entity Type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:LOREN
Last Name:COLEMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 CEDAR CT
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-5333
Mailing Address - Country:US
Mailing Address - Phone:618-549-3388
Mailing Address - Fax:618-549-3380
Practice Address - Street 1:1155 CEDAR CT
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-5333
Practice Address - Country:US
Practice Address - Phone:618-549-3388
Practice Address - Fax:618-549-3380
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036060385174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036060385Medicaid
IL036060385Medicaid