Provider Demographics
NPI:1942335930
Name:COLEMAN, MARK J
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:COLEMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 S RANDOLPH AVE
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601-5124
Mailing Address - Country:US
Mailing Address - Phone:845-471-5965
Mailing Address - Fax:845-454-2701
Practice Address - Street 1:76 FIREMENS WAY
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12603-6519
Practice Address - Country:US
Practice Address - Phone:845-452-9220
Practice Address - Fax:845-454-2701
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0128421225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist