Provider Demographics
NPI:1912904632
Name:COLEMAN, MICHAEL WAYNE (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WAYNE
Last Name:COLEMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 N COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:MO
Mailing Address - Zip Code:64402-1432
Mailing Address - Country:US
Mailing Address - Phone:660-726-5592
Mailing Address - Fax:660-726-3992
Practice Address - Street 1:606 N COLLEGE ST
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:MO
Practice Address - Zip Code:64402-1432
Practice Address - Country:US
Practice Address - Phone:660-726-5592
Practice Address - Fax:660-726-3992
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO110838207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO25664031OtherBLUE CROSS BLUE SHIELD
MO0007948Medicare ID - Type Unspecified
MO25664031OtherBLUE CROSS BLUE SHIELD