Basic Information
| Provider Information | |||||||||
| NPI: | 1255535480 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLEMAN | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | BRYCE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27128 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841270128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8016998449 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1126 DRAPER PKWY | ||||||||
| Address2: | |||||||||
| City: | DRAPER | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840209095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012502000 | ||||||||
| FaxNumber: | 8013257185 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2007 | ||||||||
| LastUpdateDate: | 09/11/2015 | ||||||||
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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 | 207Q00000X | 6029461 1205 | UT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.