Healthcare Provider Details

I. General information

NPI: 1881685782
Provider Name (Legal Business Name): BRANDON L COLEMAN D. O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 03/19/2024
Certification Date: 03/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1016 HIGHWAY 42
SUMRALL MS
39482-9634
US

IV. Provider business mailing address

PO BOX 1729
HATTIESBURG MS
39403-1729
US

V. Phone/Fax

Practice location:
  • Phone: 601-758-4214
  • Fax: 601-758-0614
Mailing address:
  • Phone: 601-545-8700
  • Fax: 601-450-0231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number17409
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: