Provider Demographics
NPI:1821088261
Name:COLEMAN, DEWITT MCINTYRE JR (M D)
Entity Type:Individual
Prefix:
First Name:DEWITT
Middle Name:MCINTYRE
Last Name:COLEMAN
Suffix:JR
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 603725
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3725
Mailing Address - Country:US
Mailing Address - Phone:828-575-2625
Mailing Address - Fax:828-350-2174
Practice Address - Street 1:103 MIDLANDS CT
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-3456
Practice Address - Country:US
Practice Address - Phone:803-794-3581
Practice Address - Fax:803-791-7286
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC27671207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA08816874OtherMEDICARE PTAN
SC276711Medicaid
SC276711Medicaid
SC20046887OtherSELECT HEALTH
SCAA08816874OtherMEDICARE PTAN
561249571OtherTIN
561249571OtherTIN
SCAA08816875Medicare PIN