Provider Demographics
NPI:1629165238
Name:COLEMAN, KELLY MARISSA (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MARISSA
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11511 SHADOW CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-7298
Mailing Address - Country:US
Mailing Address - Phone:713-442-0000
Mailing Address - Fax:
Practice Address - Street 1:10701 VINTAGE PRESERVE PKWY
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070-2158
Practice Address - Country:US
Practice Address - Phone:713-442-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM4740208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8X5380OtherBCBS
TX215629102Medicaid
TX215629102Medicaid
TX8J3698Medicare PIN