Provider Demographics
NPI:1013045913
Name:COFFEY, J CLIFTON (MD)
Entity Type:Individual
Prefix:DR
First Name:J
Middle Name:CLIFTON
Last Name:COFFEY
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 1:1900 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
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2014-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK20836207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100136650AMedicaid
OK37D0963547OtherCLIA WAIVER ID
OK100136650CMedicaid
OK731568328OtherTAX ID
OK20836OtherMEDICAL LICENSE
OK100136650CMedicaid