Provider Demographics
NPI:1174806277
Name:COLEMAN, JESSIE DANIEL JUAN (MD)
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:DANIEL JUAN
Last Name:COLEMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3215 GATEWAY BLVD W
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79903-4225
Mailing Address - Country:US
Mailing Address - Phone:915-598-7246
Mailing Address - Fax:915-633-6598
Practice Address - Street 1:3215 GATEWAY BLVD W
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79903-4225
Practice Address - Country:US
Practice Address - Phone:915-598-7246
Practice Address - Fax:915-633-6598
Is Sole Proprietor?:No
Enumeration Date:2011-09-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10844207L00000X
TXQ1377207LP2900X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX346729204Medicaid