Provider Demographics
NPI:1164460317
Name:KOFFLER, ELLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:
Last Name:KOFFLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:ELLEN
Other - Middle Name:
Other - Last Name:LAWRENCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 EDGEWATER ST
Mailing Address - Street 2:SUITE 723
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-4900
Mailing Address - Country:US
Mailing Address - Phone:718-226-1008
Mailing Address - Fax:718-226-1039
Practice Address - Street 1:475 SEAVIEW AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-3436
Practice Address - Country:US
Practice Address - Phone:718-226-6902
Practice Address - Fax:718-226-6844
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY149195207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine