Provider Demographics
NPI:1720722473
Name:BACKOFEN, JEFFREY CAMERON (DO)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:CAMERON
Last Name:BACKOFEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 BLUE JOHNSON RD
Mailing Address - Street 2:
Mailing Address - City:HOPKINS
Mailing Address - State:SC
Mailing Address - Zip Code:29061-9073
Mailing Address - Country:US
Mailing Address - Phone:909-418-4720
Mailing Address - Fax:
Practice Address - Street 1:420 POLIFKA DR BLDG 1042
Practice Address - Street 2:
Practice Address - City:SHAW AFB
Practice Address - State:SC
Practice Address - Zip Code:29152-5100
Practice Address - Country:US
Practice Address - Phone:803-895-6191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-27
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC90973171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171000000XOther Service ProvidersMilitary Health Care ProviderGroup - Single Specialty