Provider Demographics
NPI:1982647517
Name:COLEMAN, COLLEEN LINDA (MD)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:LINDA
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 1:510 SUPERIOR AVE
Mailing Address - Street 2:SUITE 200G
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-3663
Mailing Address - Country:US
Mailing Address - Phone:949-791-6767
Mailing Address - Fax:949-791-6768
Practice Address - Street 1:510 SUPERIOR AVE
Practice Address - Street 2:SUITE 200-G
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3663
Practice Address - Country:US
Practice Address - Phone:949-791-6767
Practice Address - Fax:949-791-6768
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG080909208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA10946255OtherCAQH PROVIDER ID
CA10946255OtherCAQH PROVIDER ID
CAW19783Medicare ID - Type Unspecified