Provider Demographics
NPI:1275939639
Name:COLEMAN, SHUNDOBIE T
Entity Type:Individual
Prefix:
First Name:SHUNDOBIE
Middle Name:T
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:199 RAYMOND RD STE D
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39204-2864
Mailing Address - Country:US
Mailing Address - Phone:800-807-4858
Mailing Address - Fax:800-313-1036
Practice Address - Street 1:199 RAYMOND RD STE D
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-2864
Practice Address - Country:US
Practice Address - Phone:800-807-4858
Practice Address - Fax:800-313-1036
Is Sole Proprietor?:No
Enumeration Date:2014-11-13
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No172A00000XOther Service ProvidersDriver