Provider Demographics
NPI:1255535480
Name:COLEMAN, JEREMY BRYCE (MD)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:BRYCE
Last Name:COLEMAN
Suffix:
Gender:M
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:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-699-8449
Mailing Address - Fax:
Practice Address - Street 1:1126 DRAPER PKWY
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-9095
Practice Address - Country:US
Practice Address - Phone:801-250-2000
Practice Address - Fax:801-325-7185
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6029461 1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine