Provider Demographics
NPI:1750502266
Name:COLEAN, JOHN EDWIN (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:EDWIN
Last Name:COLEAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10855 SOUTH FEDERAL HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:PORT ST. LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952
Mailing Address - Country:US
Mailing Address - Phone:772-337-4476
Mailing Address - Fax:772-335-9258
Practice Address - Street 1:10855 SOUTH FEDERAL HIGHWAY
Practice Address - Street 2:
Practice Address - City:PORT ST. LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952
Practice Address - Country:US
Practice Address - Phone:772-337-4476
Practice Address - Fax:772-335-9258
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFLOPC002229152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007231300Medicaid
FL007231300Medicaid