Provider Demographics
NPI:1093743619
Name:COLEMAN, MARY (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5005 MAIN ST
Mailing Address - Street 2:TACOMA
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98407-3168
Mailing Address - Country:US
Mailing Address - Phone:925-360-3102
Mailing Address - Fax:
Practice Address - Street 1:5005 MAIN ST
Practice Address - Street 2:TACOMA
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98407-3168
Practice Address - Country:US
Practice Address - Phone:925-360-3102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG72907208000000X
WAMD60459088208000000X, 2080P0006X, 2080P0008X
CAG0729072080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G729070Medicaid
CA00G729070Medicaid
CA00G729070Medicare PIN