Healthcare Provider Details

I. General information

NPI: 1265826523
Provider Name (Legal Business Name): DAVID THOMAS COLEMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2015
Last Update Date: 09/28/2021
Certification Date: 09/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3031 W GRAND BLVD STE 800
DETROIT MI
48202-3141
US

IV. Provider business mailing address

PO BOX 50095
SEATTLE WA
98145-5095
US

V. Phone/Fax

Practice location:
  • Phone: 800-653-6568
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License NumberMD61042543
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number4301505653
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: