Provider Demographics
NPI:1376608356
Name:COLEMAN, RANDALL CHANEY (MD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:CHANEY
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 1:2337 TAYLOR DR
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-4163
Mailing Address - Country:US
Mailing Address - Phone:503-657-9811
Mailing Address - Fax:
Practice Address - Street 1:21810 WILLAMETTE DR
Practice Address - Street 2:
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97068-3256
Practice Address - Country:US
Practice Address - Phone:503-656-6603
Practice Address - Fax:503-557-8012
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11722207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR242768Medicaid
OR0000BKWBZMedicare ID - Type Unspecified
OR242768Medicaid