Provider Demographics
NPI:1447584685
Name:DR. REGINALD O. COLEMAN M.D. PA
Entity Type:Organization
Organization Name:DR. REGINALD O. COLEMAN M.D. PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:REGINALD
Authorized Official - Middle Name:OLIVER
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:201-433-7817
Mailing Address - Street 1:2728 KENNEDY BLVD
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306
Mailing Address - Country:US
Mailing Address - Phone:201-433-7817
Mailing Address - Fax:201-433-6044
Practice Address - Street 1:2728 KENNEDY BLVD
Practice Address - Street 2:1ST FLOOR
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306
Practice Address - Country:US
Practice Address - Phone:201-433-7817
Practice Address - Fax:201-433-6044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-21
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03415800208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1283405Medicaid
NJD06509Medicare UPIN