Provider Demographics
NPI:1770920951
Name:COLEMAN, KEVIN GORDON (LAC)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:GORDON
Last Name:COLEMAN
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-3837
Mailing Address - Country:US
Mailing Address - Phone:631-457-9523
Mailing Address - Fax:
Practice Address - Street 1:38 LANDING AVE
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2711
Practice Address - Country:US
Practice Address - Phone:631-457-9523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-29
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005047-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist