Provider Demographics
NPI:1245224591
Name:PIETERNELLE, J COFFY (MD)
Entity Type:Individual
Prefix:
First Name:J
Middle Name:COFFY
Last Name:PIETERNELLE
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 1:755 N 11TH ST
Mailing Address - Street 2:SUITE P4200
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77702-1501
Mailing Address - Country:US
Mailing Address - Phone:409-899-1499
Mailing Address - Fax:409-899-1354
Practice Address - Street 1:755 N 11TH ST
Practice Address - Street 2:SUITE P4200
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1501
Practice Address - Country:US
Practice Address - Phone:409-899-1499
Practice Address - Fax:409-899-1354
Is Sole Proprietor?:No
Enumeration Date:2005-09-01
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH5946207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX127792303Medicaid
TX160036972OtherRAILROAD MEDICARE
B48649Medicare UPIN
TX81Y845Medicare PIN
TX160036972OtherRAILROAD MEDICARE