Provider Demographics
NPI:1932341310
Name:COLEMAN, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
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 1:8929 EXECUTIVE CLUB DR
Mailing Address - Street 2:
Mailing Address - City:DELMAR
Mailing Address - State:MD
Mailing Address - Zip Code:21875-2367
Mailing Address - Country:US
Mailing Address - Phone:410-845-6726
Mailing Address - Fax:
Practice Address - Street 1:WORCESTER CO. HEALTH DEPT. - BERLIN HEALTH CENTER
Practice Address - Street 2:9730 HEALTHWAY DRIVE
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811
Practice Address - Country:US
Practice Address - Phone:410-629-0164
Practice Address - Fax:410-629-0185
Is Sole Proprietor?:No
Enumeration Date:2009-03-31
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD705371101Medicaid
MD705371101Medicaid