Provider Demographics
NPI:1841491826
Name:COLEMAN, WYCHE TAYLOR III
Entity type:Individual
Prefix:
First Name:WYCHE
Middle Name:TAYLOR
Last Name:COLEMAN
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2611 GREENWOOD RD
Mailing Address - Street 2:DEPARTMENT OF FAMILY MEDICINE
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3907
Mailing Address - Country:US
Mailing Address - Phone:318-675-5000
Mailing Address - Fax:
Practice Address - Street 1:2530 BERT KOUNS INDUSTRIAL LOOP STE 116
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3153
Practice Address - Country:US
Practice Address - Phone:318-212-5901
Practice Address - Fax:318-212-5905
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.203333207W00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA09976Medicaid