Healthcare Provider Details

I. General information

NPI: 1366350050
Provider Name (Legal Business Name): ANTHONY D COLEMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2026
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21803 MASSA CIR
PECULIAR MO
64078-7817
US

IV. Provider business mailing address

21803 MASSA CIR
PECULIAR MO
64078-7817
US

V. Phone/Fax

Practice location:
  • Phone: 405-343-9837
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number22-07765
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: