Provider Demographics
NPI:1699764258
Name:COLEMAN, JACK ANDREW JR (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:ANDREW
Last Name:COLEMAN
Suffix:JR
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 1:1101-3 N. PROGRESS AVE.
Mailing Address - Street 2:
Mailing Address - City:SILOAM SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72761-4343
Mailing Address - Country:US
Mailing Address - Phone:479-549-4055
Mailing Address - Fax:479-549-4059
Practice Address - Street 1:1101-3 N. PROGRESS AVE.
Practice Address - Street 2:
Practice Address - City:SILOAM SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72761-4343
Practice Address - Country:US
Practice Address - Phone:479-549-4055
Practice Address - Fax:479-549-4059
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD16783207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3017988Medicaid
D71834Medicare UPIN
3017984Medicare ID - Type Unspecified