Healthcare Provider Details

I. General information

NPI: 1124003769
Provider Name (Legal Business Name): PHILLIP M KOFRON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 EXCELSIOR BLVD
ST LOUIS PARK MN
55426-4702
US

IV. Provider business mailing address

6465 WAYZATA BLVD STE 315
ST LOUIS PARK MN
55426-1728
US

V. Phone/Fax

Practice location:
  • Phone: 952-993-3246
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number21490
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: