Provider Demographics
NPI:1700846995
Name:COLEMAN, JOHN MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MICHAEL
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 1:4770 WHITE BEAR PARKWAY, LL
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-3394
Mailing Address - Country:US
Mailing Address - Phone:651-426-0698
Mailing Address - Fax:651-426-6439
Practice Address - Street 1:347 NORTH SMITH AVE
Practice Address - Street 2:SUITE 505
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-3367
Practice Address - Country:US
Practice Address - Phone:651-220-6260
Practice Address - Fax:651-220-7777
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN24195174400000X
MN241952080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN357705800Medicaid
MN357705800Medicaid
E75236Medicare UPIN
MN357705800Medicaid