Healthcare Provider Details

I. General information

NPI: 1942339429
Provider Name (Legal Business Name): RICHARD L KOFKOFF MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16216 BAXTER RD SUITE 250
CHESTERFIELD MO
63017-4770
US

IV. Provider business mailing address

16216 BAXTER RD SUITE 250
CHESTERFIELD MO
63017-4770
US

V. Phone/Fax

Practice location:
  • Phone: 636-532-1717
  • Fax: 636-532-5782
Mailing address:
  • Phone: 636-532-1717
  • Fax: 636-532-5782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberR6G32
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: