Provider Demographics
NPI:1386841195
Name:DR JEFFREY R COLEMAN OPTOMETRIST PA
Entity Type:Organization
Organization Name:DR JEFFREY R COLEMAN OPTOMETRIST PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:910-762-4004
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC1329152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890910GMedicaid
NC0910GOtherBCBSNC
NC0910GOtherBCBSNC
NC890910GMedicaid