Basic Information
| Provider Information | |||||||||
| NPI: | 1730158965 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COLEMAN | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | O | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 130 DESIARD ST | ||||||||
| Address2: | SUITE 355 | ||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712017319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3188077875 | ||||||||
| FaxNumber: | 3188126603 | ||||||||
| Practice Location | |||||||||
| Address1: | 109 REGENCY PL | ||||||||
| Address2: | |||||||||
| City: | WEST MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712914453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3188129999 | ||||||||
| FaxNumber: | 3183239339 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2006 | ||||||||
| LastUpdateDate: | 04/10/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204D00000X | MD.06658R | LA | N | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM | 207Q00000X | DO306658R | LA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1349321 | 05 | LA | MEDICAID |