Provider Demographics
NPI:1033179684
Name:COFAS INC
Entity Type:Organization
Organization Name:COFAS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MD
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:COFAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-882-3818
Mailing Address - Street 1:2218 SHALLOCK AVE
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-4290
Mailing Address - Country:US
Mailing Address - Phone:541-882-3818
Mailing Address - Fax:541-882-9800
Practice Address - Street 1:2218 SHALLOCK AVE
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-4290
Practice Address - Country:US
Practice Address - Phone:541-882-3818
Practice Address - Fax:541-882-9800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-27
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD11585207Q00000X
ORMD25846207R00000X
ORPA01446363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR027754Medicaid
ORDE8224OtherRAILROAD MEDICARE
ORDE8224OtherRAILROAD MEDICARE