Provider Demographics
NPI:1528058096
Name:COLEMAN, CLARENCE C JR (MD)
Entity type:Individual
Prefix:
First Name:CLARENCE
Middle Name:C
Last Name:COLEMAN
Suffix:JR
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 1:3600 MINNESOTA DR STE 800
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-7915
Mailing Address - Country:US
Mailing Address - Phone:952-595-1301
Mailing Address - Fax:612-294-4903
Practice Address - Street 1:3600 MINNESOTA DR STE 800
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-7915
Practice Address - Country:US
Practice Address - Phone:952-595-1301
Practice Address - Fax:612-294-4903
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1330752085R0202X
NC2015-020832085R0202X
CAA603192085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACJ8758Medicare ID - Type UnspecifiedDCI RAILROAD GRP#
CACK5631Medicare ID - Type UnspecifiedQUEST RAILROAD GRP#
CAZZZ23968ZMedicare ID - Type UnspecifiedQUEST GRP MEDICARE#
CAZZZ37754ZMedicare ID - Type UnspecifiedDCI GRP MEDICARE#
CAGR0064350Medicaid
CAGR0092570Medicaid
CAH73532Medicare UPIN
CA00A603190Medicaid
CA00A603190Medicare ID - Type Unspecified