Provider Demographics
NPI:1003841271
Name:HOFMANN, MICHAEL DAVID (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:HOFMANN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12063
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-2063
Mailing Address - Country:US
Mailing Address - Phone:910-353-2660
Mailing Address - Fax:910-353-2770
Practice Address - Street 1:3050 HENDERSON DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-5246
Practice Address - Country:US
Practice Address - Phone:910-353-2660
Practice Address - Fax:910-353-2770
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-084766208000000X, 2084N0402X
MO2007035010208000000X, 2084N0402X
NC2012-018182084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO204610505Medicaid
MO204610505Medicaid
MO330725236Medicare PIN