Provider Demographics
NPI:1659359537
Name:HALL, JUAWANA COLEMAN (OD)
Entity Type:Individual
Prefix:DR
First Name:JUAWANA
Middle Name:COLEMAN
Last Name:HALL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2341 WINTERHAVEN LN
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6792
Mailing Address - Country:US
Mailing Address - Phone:336-760-2020
Mailing Address - Fax:336-760-2858
Practice Address - Street 1:2341 WINTERHAVEN LN
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6792
Practice Address - Country:US
Practice Address - Phone:336-760-2020
Practice Address - Fax:336-310-0010
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2000152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5902677Medicaid
NC2473855Medicare ID - Type Unspecified
NCV07132Medicare UPIN
NC5902677Medicaid