Healthcare Provider Details

I. General information

NPI: 1336306497
Provider Name (Legal Business Name): JACOB HEINZ HOFER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2008
Last Update Date: 09/15/2022
Certification Date: 09/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 BOWNE DR
WALDEN NY
12586-2832
US

IV. Provider business mailing address

151 BOWNE DR
WALDEN NY
12586-2832
US

V. Phone/Fax

Practice location:
  • Phone: 845-572-3477
  • Fax:
Mailing address:
  • Phone: 845-572-3477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD442316
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number23851
License Number StateWV
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number261393
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: