Provider Demographics
NPI:1619231966
Name:BACKOFEN, GREGORY S (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:S
Last Name:BACKOFEN
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 1:2421 WORTH ST
Mailing Address - Street 2:
Mailing Address - City:HEMPHILL
Mailing Address - State:TX
Mailing Address - Zip Code:75948-7215
Mailing Address - Country:US
Mailing Address - Phone:409-787-1416
Mailing Address - Fax:
Practice Address - Street 1:460 W OAK ST
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:AR
Practice Address - Zip Code:71730-4567
Practice Address - Country:US
Practice Address - Phone:870-881-4463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-02
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ5755208D00000X
ARE-9281208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice