Healthcare Provider Details

I. General information

NPI: 1356338487
Provider Name (Legal Business Name): KEVIN K KOFFEL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 05/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3439 GRANITE CIR
TOLEDO OH
43617-1161
US

IV. Provider business mailing address

3439 GRANITE CIR
TOLEDO OH
43617-1161
US

V. Phone/Fax

Practice location:
  • Phone: 419-843-7996
  • Fax: 419-841-7725
Mailing address:
  • Phone: 419-843-7996
  • Fax: 419-841-7725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number35045739K
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: