Provider Demographics
NPI:1063527224
Name:COFFEY, DORSEY SHANTEL (LSA)
Entity type:Individual
Prefix:
First Name:DORSEY
Middle Name:SHANTEL
Last Name:COFFEY
Suffix:
Gender:F
Credentials:LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7200 FLYNN CIR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78736-3053
Mailing Address - Country:US
Mailing Address - Phone:512-771-8731
Mailing Address - Fax:512-288-9858
Practice Address - Street 1:7200 FLYNN CIR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78736-3053
Practice Address - Country:US
Practice Address - Phone:512-771-8731
Practice Address - Fax:512-288-9858
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00060208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0007LFOtherBCBS
TXSA00060OtherSTATE LICENSE NUMBER