Provider Demographics
NPI:1609880541
Name:COLEMAN, SUSAN BETTINA (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:BETTINA
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:BETTINA
Other - Last Name:FORTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1518 MULBERRY AVE
Mailing Address - Street 2:
Mailing Address - City:MUSCATINE
Mailing Address - State:IA
Mailing Address - Zip Code:52761-3433
Mailing Address - Country:US
Mailing Address - Phone:563-264-9424
Mailing Address - Fax:563-264-9195
Practice Address - Street 1:1518 MULBERRY AVE
Practice Address - Street 2:
Practice Address - City:MUSCATINE
Practice Address - State:IA
Practice Address - Zip Code:52761-3433
Practice Address - Country:US
Practice Address - Phone:563-264-9424
Practice Address - Fax:563-264-9195
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY28863207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0739342Medicaid
F41213Medicare UPIN
IA0739342Medicaid