Healthcare Provider Details

I. General information

NPI: 1104310952
Provider Name (Legal Business Name): JACOB HARRY KOFFER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2018
Last Update Date: 03/20/2024
Certification Date: 03/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 W TABOR RD STE 145
PHILADELPHIA PA
19141-3019
US

IV. Provider business mailing address

101 E OLNEY AVE STE 400
PHILADELPHIA PA
19120-2470
US

V. Phone/Fax

Practice location:
  • Phone: 215-456-9475
  • Fax: 215-456-9529
Mailing address:
  • Phone: 215-456-7000
  • Fax: 215-456-5926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberMT215162
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: