Basic Information
| Provider Information | |||||||||
| NPI: | 1710977871 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLEMAN | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | WENDELL | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 AIRPORT RD | ||||||||
| Address2: | |||||||||
| City: | RIFLE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 816508510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706251100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 501 AIRPORT RD | ||||||||
| Address2: | |||||||||
| City: | RIFLE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 816508510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706251100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2005 | ||||||||
| LastUpdateDate: | 02/14/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 47061 | CO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 15486265 | 05 | CO | MEDICAID | 1710977871 | 01 | NPI | OTHER |