Provider Demographics
NPI:1114982931
Name:COLEMAN, RYAN J (MD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:J
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 1:8581 SANTA MONICA BLVD # 67
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90069-4120
Mailing Address - Country:US
Mailing Address - Phone:310-994-3672
Mailing Address - Fax:
Practice Address - Street 1:8581 SANTA MONICA BLVD # 67
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90069-4120
Practice Address - Country:US
Practice Address - Phone:310-994-3672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL52872085R0202X
CAC543862085R0202X
AZ401502085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ372255Medicaid
TX156031008Medicaid
AZZ125153Medicare PIN
AZZ133435Medicare PIN
TXP00341185Medicare PIN
H78290Medicare UPIN
AZ372255Medicaid