Provider Demographics
NPI: | 1457315756 |
---|---|
Name: | COLEMAN, JOHN JOSEPH (DPM) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | JOHN |
Middle Name: | JOSEPH |
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: | 159 N 3RD ST |
Mailing Address - Street 2: | |
Mailing Address - City: | MACCLENNY |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 32063-2103 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 904-259-5277 |
Mailing Address - Fax: | 904-653-4677 |
Practice Address - Street 1: | 159 N 3RD ST |
Practice Address - Street 2: | |
Practice Address - City: | MACCLENNY |
Practice Address - State: | FL |
Practice Address - Zip Code: | 32063-2103 |
Practice Address - Country: | US |
Practice Address - Phone: | 904-259-5277 |
Practice Address - Fax: | 904-653-4677 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2006-04-13 |
Last Update Date: | 2017-04-25 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
FL | PO0001570 | 213E00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 213E00000X | Podiatric Medicine & Surgery Service Providers | Podiatrist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
FL | 480030619 | Other | RAILROAD MEDICARE |
FL | 87929 | Other | BLUE CROSS BLUE SHIELD |
FL | 029623600 | Medicaid | |
FL | 87929D | Medicare PIN | |
FL | 87929D | Medicare ID - Type Unspecified | |
FL | 029623600 | Medicaid |