Provider Demographics
NPI:1922440494
Name:COLEMAN, JUSTIN ERIC (OD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:ERIC
Last Name:COLEMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:25 STERLING WAY
Mailing Address - Street 2:STE C
Mailing Address - City:MOUNT STERLING
Mailing Address - State:KY
Mailing Address - Zip Code:40353-1174
Mailing Address - Country:US
Mailing Address - Phone:859-498-4800
Mailing Address - Fax:859-498-2021
Practice Address - Street 1:25 STERLING WAY
Practice Address - Street 2:STE C
Practice Address - City:MOUNT STERLING
Practice Address - State:KY
Practice Address - Zip Code:40353-1174
Practice Address - Country:US
Practice Address - Phone:859-498-4800
Practice Address - Fax:859-498-2021
Is Sole Proprietor?:No
Enumeration Date:2013-07-24
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1938DT152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100261660Medicaid