Healthcare Provider Details

I. General information

NPI: 1710080759
Provider Name (Legal Business Name): MARK ROBERT COFFMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3811 SAGEBRIAR DRIVE
BRYAN TX
77802-6107
US

IV. Provider business mailing address

5022 AUGUSTA CIRCLE
COLLEGE STATION TX
77845-8983
US

V. Phone/Fax

Practice location:
  • Phone: 979-774-0498
  • Fax:
Mailing address:
  • Phone: 979-690-7335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberE6286
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: