Healthcare Provider Details

I. General information

NPI: 1619231966
Provider Name (Legal Business Name): GREGORY S. BACKOFEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2012
Last Update Date: 09/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 W OAK ST
EL DORADO AR
71730-4567
US

IV. Provider business mailing address

2421 WORTH ST
HEMPHILL TX
75948-7215
US

V. Phone/Fax

Practice location:
  • Phone: 870-881-4463
  • Fax:
Mailing address:
  • Phone: 409-787-1416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberQ5755
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberE-9281
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: