Healthcare Provider Details

I. General information

NPI: 1023231420
Provider Name (Legal Business Name): LAVAR W KOFOED O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 04/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

291 N MILWAUKEE ST
BOISE ID
83704-9132
US

IV. Provider business mailing address

291 N MILWAUKEE ST
BOISE ID
83704-9132
US

V. Phone/Fax

Practice location:
  • Phone: 208-378-7020
  • Fax: 208-378-9460
Mailing address:
  • Phone: 208-378-7020
  • Fax: 208-375-7970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODP-972
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: