Provider Demographics
NPI:1801125265
Name:CLENTON COLEMAN MD PC
Entity type:Organization
Organization Name:CLENTON COLEMAN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:CLENTON
Authorized Official - Middle Name:L
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-836-7970
Mailing Address - Street 1:222 CEDAR LN STE 109
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-4311
Mailing Address - Country:US
Mailing Address - Phone:201-379-5650
Mailing Address - Fax:201-357-8206
Practice Address - Street 1:222 CEDAR LN STE 109
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-4311
Practice Address - Country:US
Practice Address - Phone:201-379-5650
Practice Address - Fax:201-357-8206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-14
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08555000207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0108251Medicaid