Provider Demographics
NPI:1851340111
Name:COLEMAN, JANICE LARK (MD)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:LARK
Last Name:COLEMAN
Suffix:
Gender:F
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:PO BOX 402145
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-2145
Mailing Address - Country:US
Mailing Address - Phone:803-296-7305
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:9 RICHLAND MEDICAL PARK
Practice Address - Street 2:SUITE 620
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6859
Practice Address - Country:US
Practice Address - Phone:803-779-6776
Practice Address - Fax:803-779-7346
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9009174400000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC090092Medicaid
SC090092Medicaid
SCD09196Medicare UPIN