Provider Demographics
NPI:1639170301
Name:COLEMAN, DAVID EUGENE (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:EUGENE
Last Name:COLEMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4425 N PORT WASHINGTON RD
Mailing Address - Street 2:ASCENSION CORP
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-1082
Mailing Address - Country:US
Mailing Address - Phone:414-326-2218
Mailing Address - Fax:
Practice Address - Street 1:1855 S KOELLER ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54902-6186
Practice Address - Country:US
Practice Address - Phone:920-223-4410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI146D00000X
WI25223-020207Q00000X, 208600000X
WI25223207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30527900Medicaid
WIB52148Medicare UPIN
WI002300416Medicare ID - Type Unspecified