Provider Demographics
NPI:1821071093
Name:COLEMAN, MARILYN JOY (MD)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:JOY
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:119 AMBULANCE DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3857
Mailing Address - Country:US
Mailing Address - Phone:770-834-0606
Mailing Address - Fax:770-834-1833
Practice Address - Street 1:804 DIXIE ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-4416
Practice Address - Country:US
Practice Address - Phone:770-834-0606
Practice Address - Fax:770-834-1833
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA056034208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA698666059CMedicaid