Provider Demographics
NPI:1942306311
Name:COALTER, JOHN DOUGLAS (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DOUGLAS
Last Name:COALTER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:3701 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-7310
Practice Address - Country:US
Practice Address - Phone:219-872-8844
Practice Address - Fax:219-874-2872
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002563A 18002563B152W00000X, 152WC0802X, 152WX0102X, 152WL0500X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
T38563Medicare UPIN
L32605Medicare ID - Type Unspecified
410030600Medicare ID - Type UnspecifiedRR