Healthcare Provider Details

I. General information

NPI: 1861423360
Provider Name (Legal Business Name): IVAN BRUCE HOFFMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 08/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4015 S COBB DR SE SUITE 220
SMYRNA GA
30080-6303
US

IV. Provider business mailing address

4015 S COBB DR SE SUITE 220
SMYRNA GA
30080-6303
US

V. Phone/Fax

Practice location:
  • Phone: 770-801-0980
  • Fax: 770-801-9039
Mailing address:
  • Phone: 770-801-0980
  • Fax: 770-801-9039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number36396
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number36396
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: