Provider Demographics
NPI:1326047689
Name:COLEMAN, JEFFREY R (OD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:R
Last Name:COLEMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 S 16TH ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-8015
Mailing Address - Country:US
Mailing Address - Phone:910-762-4004
Mailing Address - Fax:910-762-1605
Practice Address - Street 1:919 S 16TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-8015
Practice Address - Country:US
Practice Address - Phone:910-762-4004
Practice Address - Fax:910-762-1605
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1329152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890910GMedicaid
NCU01286Medicare UPIN
NC890910GMedicaid