Provider Demographics
NPI:1528130234
Name:COLEMAN, KEVIN B
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:B
Last Name:COLEMAN
Suffix:
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 1:1125 STERLING PLACE
Mailing Address - Street 2:APT 1E
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11213-2679
Mailing Address - Country:US
Mailing Address - Phone:718-778-2513
Mailing Address - Fax:
Practice Address - Street 1:1125 STERLING PL 1E
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11213-2679
Practice Address - Country:US
Practice Address - Phone:718-778-2513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN0043111174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01041941Medicaid
NY01041941Medicaid
NYT51454Medicare UPIN