Provider Demographics
NPI:1366440380
Name:COFFMAN, EDWIN L (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:L
Last Name:COFFMAN
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:PO BOX 1824
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72902-1824
Mailing Address - Country:US
Mailing Address - Phone:479-709-7399
Mailing Address - Fax:479-709-7053
Practice Address - Street 1:1001 TOWSON AVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-4921
Practice Address - Country:US
Practice Address - Phone:479-441-5362
Practice Address - Fax:479-441-4868
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC2686207L00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100078260AMedicaid
AR105564001MedicaidMEDICAID PROVIDER NUMBER
AR51096OtherARKANSAS BCBS
ARC68046Medicare UPINUPIN NUMBER
AR105564001MedicaidMEDICAID PROVIDER NUMBER