1407021702 NPI number — DR. NATHANIEL DAVID KOFFORD M.D., MSPH

Table of content: DR. NATHANIEL DAVID KOFFORD M.D., MSPH (NPI 1407021702)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407021702 NPI number — DR. NATHANIEL DAVID KOFFORD M.D., MSPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOFFORD
Provider First Name:
NATHANIEL
Provider Middle Name:
DAVID
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D., MSPH
Provider Gender Code:
M

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:
1407021702
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/05/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3340 N CENTER ST
Provider Second Line Business Mailing Address:
#800
Provider Business Mailing Address City Name:
LEHI
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84043-7406
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-990-1911
Provider Business Mailing Address Fax Number:
801-990-1912

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 ROUND VALLEY DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PARK CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84060-7532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-658-7000
Provider Business Practice Location Address Fax Number:
801-990-1912
Provider Enumeration Date:
04/28/2008

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: 207L00000X , with the licence number:  042-0011896 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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