Provider Demographics
NPI:1881685782
Name:COLEMAN, BRANDON L (D O)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:L
Last Name:COLEMAN
Suffix:
Gender:M
Credentials:D O
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1729
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39403-1729
Mailing Address - Country:US
Mailing Address - Phone:601-545-8700
Mailing Address - Fax:601-450-0231
Practice Address - Street 1:1016 HIGHWAY 42
Practice Address - Street 2:
Practice Address - City:SUMRALL
Practice Address - State:MS
Practice Address - Zip Code:39482-9634
Practice Address - Country:US
Practice Address - Phone:601-758-4214
Practice Address - Fax:601-758-0614
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17409207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS2086469OtherUNITED HEALTH CARE
MS7034349OtherAETNA
MS71590-BOtherHUMANA/TRICARE
MS1143078OtherCAQH ID NUMBER
MSP00157321OtherRAILROAD MEDICARE
MS405915OtherWINDSOR HEALTH GROUP
MS1043492770OtherFIRST CHOICE OF MISSISSIPPI
MS8048940P04OtherCIGNA
MS00125342Medicaid
MS405915OtherWINDSOR HEALTH GROUP
MS1143078OtherCAQH ID NUMBER