Provider Demographics
NPI:1730379025
Name:COLEMAN, CLENTON L (MD)
Entity type:Individual
Prefix:
First Name:CLENTON
Middle Name:L
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 1:222 CEDAR LN STE 109
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-4311
Mailing Address - Country:US
Mailing Address - Phone:201-379-5650
Mailing Address - Fax:201-357-8206
Practice Address - Street 1:222 CEDAR LN STE 109
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-4311
Practice Address - Country:US
Practice Address - Phone:201-379-5650
Practice Address - Fax:201-357-8206
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-01
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY245332207R00000X
NJ25MA08555000207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0108251Medicaid