Provider Demographics
NPI:1346315181
Name:DR JEFF BROFFMAN A MEDICAL CORP
Entity Type:Organization
Organization Name:DR JEFF BROFFMAN A MEDICAL CORP
Other - Org Name:JEFFERY BROFFMAN MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NENA
Authorized Official - Middle Name:
Authorized Official - Last Name:KNIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-526-7920
Mailing Address - Street 1:1144 SONOMA AVE
Mailing Address - Street 2:#101
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405
Mailing Address - Country:US
Mailing Address - Phone:707-526-7920
Mailing Address - Fax:707-526-0459
Practice Address - Street 1:1144 SONOMA AVE
Practice Address - Street 2:#101
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405
Practice Address - Country:US
Practice Address - Phone:707-526-7920
Practice Address - Fax:707-526-0459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG53420207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G534200Medicaid
ZZZ32506ZMedicare ID - Type Unspecified
E50050Medicare UPIN