Provider Demographics
NPI:1407831308
Name:COLEMAN, WALTER BARRY (DPM)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:BARRY
Last Name:COLEMAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9001 15 MILE RD
Mailing Address - Street 2:STE A
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48312-3611
Mailing Address - Country:US
Mailing Address - Phone:586-979-0560
Mailing Address - Fax:586-949-8766
Practice Address - Street 1:9001 15 MILE RD
Practice Address - Street 2:STE A
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48312-3611
Practice Address - Country:US
Practice Address - Phone:586-979-0560
Practice Address - Fax:586-979-8766
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901000563213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI55051630OtherBCBS
MI1002476Medicaid
0621950001OtherNPIN DME
T34059Medicare UPIN
MI1002476Medicaid