Healthcare Provider Details

I. General information

NPI: 1710984513
Provider Name (Legal Business Name): WYCHE TAYLOR COLEMAN JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 07/26/2023
Certification Date: 07/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1633 MARVEL ST
COUSHATTA LA
71019-9022
US

IV. Provider business mailing address

1633 MARVEL ST
COUSHATTA LA
71019-9022
US

V. Phone/Fax

Practice location:
  • Phone: 318-932-9980
  • Fax: 318-932-9906
Mailing address:
  • Phone: 318-932-9980
  • Fax: 318-932-9906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number015031
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number015031
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: