Provider Demographics
NPI:1215089818
Name:DENNIS W COFFMAN M D
Entity type:Organization
Organization Name:DENNIS W COFFMAN M D
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:W
Authorized Official - Last Name:COFFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-564-7383
Mailing Address - Street 1:4800 NE STALLINGS
Mailing Address - Street 2:SUITE 112
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965
Mailing Address - Country:US
Mailing Address - Phone:936-564-7033
Mailing Address - Fax:936-564-7909
Practice Address - Street 1:4800 NE STALLINGS
Practice Address - Street 2:SUITE 112
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965
Practice Address - Country:US
Practice Address - Phone:936-564-7033
Practice Address - Fax:936-564-7909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CL8273Medicare ID - Type Unspecified