Provider Demographics
NPI:1447258694
Name:COLEMAN, MICHAEL WALLACE (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WALLACE
Last Name:COLEMAN
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 HIGHWAY 82 W
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38930-2720
Mailing Address - Country:US
Mailing Address - Phone:662-455-4523
Mailing Address - Fax:662-455-3790
Practice Address - Street 1:2005 HIGHWAY 82 W
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930-2720
Practice Address - Country:US
Practice Address - Phone:662-455-4523
Practice Address - Fax:662-455-3790
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-12
Last Update Date:2025-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS06711207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS180041706OtherR/R MEDICARE
MS00124307Medicaid
MS180041706OtherR/R MEDICARE
MSB64643Medicare UPIN
MS180000255Medicare ID - Type Unspecified