1265788715 NPI number — DR. MIRANDA M GARAY KOFELDT PHD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265788715 NPI number — DR. MIRANDA M GARAY KOFELDT PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOFELDT
Provider First Name:
MIRANDA
Provider Middle Name:
M GARAY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GARAY
Provider Other First Name:
MIRANDA
Provider Other Middle Name:
MICHELE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1265788715
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
701 W PRATT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21201-1023
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-328-6018
Provider Business Mailing Address Fax Number:
410-328-6391

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 W PRATT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21201-1023
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-328-6018
Provider Business Practice Location Address Fax Number:
410-328-6391
Provider Enumeration Date:
08/01/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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