Provider Demographics
NPI:1285612879
Name:COLEMAN, TED (MD)
Entity type:Individual
Prefix:DR
First Name:TED
Middle Name:
Last Name:COLEMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11102 SUNRISE BLVD E,
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374
Mailing Address - Country:US
Mailing Address - Phone:253-848-8797
Mailing Address - Fax:253-845-0100
Practice Address - Street 1:11102 SUNRISE BLVD E
Practice Address - Street 2:SUITE 103
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374
Practice Address - Country:US
Practice Address - Phone:253-848-8797
Practice Address - Fax:253-845-0100
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301046463207P00000X
WAMD60597143207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
11273896OtherCAQH
WA1285612879Medicaid