MEDICARE: KENNETH R. KOFOED M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	7423	UT

General Provider Information

NPI Number	:	1972681021
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH R. KOFOED M.D.

Provider Business Mailing Address
First Line	:	PO BOX 786
Second Line	:
City	:	LAYTON
State	:	UT
Zip	:	84041-0786
Country	:	US
Telephone Number	:	801-771-3024
Fax Number	:

Provider Business Practice Location Address
First Line	:	1660 W ANTELOPE DR
Second Line	:	SUIT 115
City	:	LAYTON
State	:	UT
Zip	:	84041-1156
Country	:	US
Telephone Number	:	801-771-3024
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/02/2006
Last Update Date	:	07/08/2007

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