1053348920 NPI number — LORI A COLEMAN MD

Table of content: LORI A COLEMAN MD (NPI 1053348920)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053348920 NPI number — LORI A COLEMAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COLEMAN
Provider First Name:
LORI
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053348920
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/12/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5725 KEARNY VILLA ROAD
Provider Second Line Business Mailing Address:
SUITE I
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92123-1134
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-256-0351
Provider Business Mailing Address Fax Number:
858-256-0355

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
769 MEDICAL CENTER COURT
Provider Second Line Business Practice Location Address:
CANCER CENTER
Provider Business Practice Location Address City Name:
CHULA VISTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91911
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-502-5851
Provider Business Practice Location Address Fax Number:
619-502-5865
Provider Enumeration Date:
06/27/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  G78635 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0001X , with the licence number: G78635 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: G78635 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 00G786350 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".