Provider Demographics
NPI:1760404792
Name:COLEMAN, WILLIAM R (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:R
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 1:9535 RESEDA BOULEVARD
Mailing Address - Street 2:SUITE 304
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91324-6029
Mailing Address - Country:US
Mailing Address - Phone:818-886-3884
Mailing Address - Fax:818-886-5418
Practice Address - Street 1:9535 RESEDA BOULEVARD
Practice Address - Street 2:SUITE 304
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91324-6029
Practice Address - Country:US
Practice Address - Phone:818-886-3884
Practice Address - Fax:818-886-5418
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG67719207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
W10554Medicare ID - Type Unspecified
E92122Medicare UPIN