Provider Demographics
NPI:1588777361
Name:COLEMAN, KYLE M (MD)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:M
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 1:404 N ACADIA RD
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-4856
Mailing Address - Country:US
Mailing Address - Phone:985-447-3889
Mailing Address - Fax:985-446-2483
Practice Address - Street 1:404 N ACADIA RD
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-4856
Practice Address - Country:US
Practice Address - Phone:985-447-3889
Practice Address - Fax:985-446-2483
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA201271207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1090719Medicaid
LA1090719Medicaid
TX8L15037Medicare PIN
TX8L15037Medicare PIN