1255680674 NPI number — DENNIS W COFFMAN M.D.

Table of content: (NPI 1255680674)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255680674 NPI number — DENNIS W COFFMAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DENNIS W COFFMAN M.D.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255680674
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4800 N E STALLINGS DRIVE
Provider Second Line Business Mailing Address:
SUITE 111
Provider Business Mailing Address City Name:
NACOGDOCHES
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75965-1250
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
936-564-7383
Provider Business Mailing Address Fax Number:
936-569-0549

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4800 N E STALLINGS DRIVE
Provider Second Line Business Practice Location Address:
SUITE 111
Provider Business Practice Location Address City Name:
NACOGDOCHES
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75965-1250
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-564-7383
Provider Business Practice Location Address Fax Number:
936-569-0549
Provider Enumeration Date:
08/30/2012

Additional Information

Authorized Official

Authorized Official Last Name:
COFFMAN
Authorized Official First Name:
DENNIS
Authorized Official Middle Name:
W
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
936-564-7383

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  EO423 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 115582201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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