Healthcare Provider Details

I. General information

NPI: 1003984493
Provider Name (Legal Business Name): WYCHE T. COLEMAN, M.D., LIMITED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1633 MARVEL STREET
COUSHATTA LA
71019
US

IV. Provider business mailing address

1633 MARVEL STREET
COUSHATTA LA
71019
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 TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number015031
License Number StateLA

VIII. Authorized Official

Name: WYCHE TAYLOR COLEMAN
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 318-932-9980