Provider Demographics
NPI:1225104839
Name:COLEMAN, LARRY B
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:B
Last Name:COLEMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 TOWN MT RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41501
Mailing Address - Country:US
Mailing Address - Phone:606-432-5806
Mailing Address - Fax:606-432-8174
Practice Address - Street 1:419 TOWN MT RD
Practice Address - Street 2:SUITE 102
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501
Practice Address - Country:US
Practice Address - Phone:606-432-5806
Practice Address - Fax:606-432-8174
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY22906207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C68002Medicare UPIN