Provider Demographics
NPI:1003896010
Name:KOEFOOT, RICHARD BRUCE (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:BRUCE
Last Name:KOEFOOT
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 1:620 N ALPHA ST
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-4316
Mailing Address - Country:US
Mailing Address - Phone:308-381-0473
Mailing Address - Fax:308-381-2616
Practice Address - Street 1:620 N ALPHA ST
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-4316
Practice Address - Country:US
Practice Address - Phone:308-381-0473
Practice Address - Fax:308-381-2616
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE18143174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE00378OtherBLUE CROSS
NE247460OtherMIDLANDS CHOICE
NEP00241093OtherRAILROAD MEDICARE
NEP00241093OtherRAILROAD MEDICARE
NE279212Medicare ID - Type UnspecifiedPROVIDER NUMBER