Provider Demographics
NPI:1710984513
Name:COLEMAN, WYCHE TAYLOR JR (MD)
Entity Type:Individual
Prefix:MR
First Name:WYCHE
Middle Name:TAYLOR
Last Name:COLEMAN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1633 MARVEL ST
Mailing Address - Street 2:
Mailing Address - City:COUSHATTA
Mailing Address - State:LA
Mailing Address - Zip Code:71019-9022
Mailing Address - Country:US
Mailing Address - Phone:318-932-9980
Mailing Address - Fax:318-932-9906
Practice Address - Street 1:1633 MARVEL ST
Practice Address - Street 2:
Practice Address - City:COUSHATTA
Practice Address - State:LA
Practice Address - Zip Code:71019-9022
Practice Address - Country:US
Practice Address - Phone:318-932-9980
Practice Address - Fax:318-932-9906
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA015031207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1303003Medicaid
LA51877Medicare PIN
LA323941YWM2Medicare PIN
LAB63436Medicare UPIN