Provider Demographics
NPI:1700040748
Name:COLEMAN, BROOKE A (OD)
Entity Type:Individual
Prefix:DR
First Name:BROOKE
Middle Name:A
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:A
Other - Last Name:COLEMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:3953 W STETSON AVE
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92545-9687
Mailing Address - Country:US
Mailing Address - Phone:951-652-4343
Mailing Address - Fax:951-765-6039
Practice Address - Street 1:3953 W STETSON AVE
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92545-9687
Practice Address - Country:US
Practice Address - Phone:951-652-4343
Practice Address - Fax:951-765-6039
Is Sole Proprietor?:No
Enumeration Date:2008-07-17
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13551152W00000X
CAOPT1355TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT13551TOtherBOARD OF OPTOMETRY