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General NPI Number Information
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NPI Number | 1619231966
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Entity Type | Individual
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Provider Name | GREGORY S. BACKOFEN M.D.
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Gender | Male
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Dates
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Enumeration Date | 07/02/2012
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Last Update Date | 09/08/2015
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Provider Practice Location Address
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Address Line | 460 W OAK ST
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City | EL DORADO
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State | AR
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Zip | 71730-4567
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Country | US
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Telephone | 870-881-4463
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Fax |
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Provider Business Mailing Address
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Address Line | 2421 WORTH ST
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City | HEMPHILL
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State | TX
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Zip | 75948-7215
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Country | US
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Telephone | 409-787-1416
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | Q5755
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | E-9281
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License Number State | AR
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