Healthcare Provider Details

I. General information

NPI: 1952362717
Provider Name (Legal Business Name): BARRY A KOFFLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 04/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1295 HEMBREE RD SUITE 200A
ROSWELL GA
30076-5721
US

IV. Provider business mailing address

1295 HEMBREE RD SUITE 200A
ROSWELL GA
30076-5721
US

V. Phone/Fax

Practice location:
  • Phone: 770-475-1279
  • Fax: 770-442-5444
Mailing address:
  • Phone: 770-475-1279
  • Fax: 770-442-5444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number19540
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: