Provider Demographics
NPI:1386755072
Name:J COFFEY MD PC
Entity type:Organization
Organization Name:J COFFEY MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:COFFEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-225-9222
Mailing Address - Street 1:1900 W 2ND ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:ELK CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73644-4328
Mailing Address - Country:US
Mailing Address - Phone:580-225-9222
Mailing Address - Fax:580-225-1027
Practice Address - Street 1:1900 W 2ND ST
Practice Address - Street 2:SUITE C
Practice Address - City:ELK CITY
Practice Address - State:OK
Practice Address - Zip Code:73644-4328
Practice Address - Country:US
Practice Address - Phone:580-225-9222
Practice Address - Fax:580-225-1027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK20836207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100136650AMedicaid
OK20836OtherMEDICAL LICENSE NUMBER
OK37D0963547OtherCLIA WAIVER NUMBER
OK448604592-001OtherBC BS OF OK PROVIDER ID
OK100136650DMedicaid
OK100136650CMedicaid
OK100136650DMedicaid