Provider Demographics
NPI:1104129162
Name:COLEMAN, JEFFREY RAY (OD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:RAY
Last Name:COLEMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15220 MONTFORT DR.
Mailing Address - Street 2:1001
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75248
Mailing Address - Country:US
Mailing Address - Phone:972-239-1530
Mailing Address - Fax:972-239-0840
Practice Address - Street 1:15220 MONTFORT RD
Practice Address - Street 2:1001
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75248-6401
Practice Address - Country:US
Practice Address - Phone:972-239-1530
Practice Address - Fax:972-239-0840
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-14
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7320152W00000X, 152WC0802X, 152WS0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision