Healthcare Provider Details

I. General information

NPI: 1659543247
Provider Name (Legal Business Name): JEFFERY BROFFMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2008
Last Update Date: 03/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1144 SONOMA AVE SUITE 101
SANTA ROSA CA
95405-4812
US

IV. Provider business mailing address

1144 SONOMA AVE SUITE 101
SANTA ROSA CA
95405-4812
US

V. Phone/Fax

Practice location:
  • Phone: 707-526-7920
  • Fax: 707-546-5334
Mailing address:
  • Phone: 707-526-7920
  • Fax: 707-546-5334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License NumberG53420
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: