Healthcare Provider Details

I. General information

NPI: 1184048142
Provider Name (Legal Business Name): HERBERT KOFFLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2014
Last Update Date: 02/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 AGUA SARCA RD
PLACITAS NM
87043-9405
US

IV. Provider business mailing address

41 AGUA SARCA RD
PLACITAS NM
87043-9405
US

V. Phone/Fax

Practice location:
  • Phone: 505-867-5253
  • Fax:
Mailing address:
  • Phone: 505-867-5253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number74-189
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number74-189
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: