Provider Demographics
NPI:1932330644
Name:DAVID R COLEMAN OD LLC
Entity Type:Organization
Organization Name:DAVID R COLEMAN OD LLC
Other - Org Name:COLEMAN VISION IMPROVEMENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:R
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:TO2322
Authorized Official - Phone:417-782-3488
Mailing Address - Street 1:1030 SE MURPHY BLVD
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64801-5043
Mailing Address - Country:US
Mailing Address - Phone:417-782-3488
Mailing Address - Fax:417-782-8150
Practice Address - Street 1:1030 SE MURPHY BLVD
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-5043
Practice Address - Country:US
Practice Address - Phone:417-782-3488
Practice Address - Fax:417-782-8150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-29
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOTO2322152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100090450BMedicaid
MO311427801Medicaid
MO311427801Medicaid