Provider Demographics
NPI:1649235300
Name:COFFMAN, STEPHAN W (MD)
Entity Type:Individual
Prefix:
First Name:STEPHAN
Middle Name:W
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 1193
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1193
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1304 MONTELLO AVE
Practice Address - Street 2:
Practice Address - City:HOOD RIVER
Practice Address - State:OR
Practice Address - Zip Code:97031-1544
Practice Address - Country:US
Practice Address - Phone:541-387-8992
Practice Address - Fax:541-387-6269
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD24190208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR181694Medicaid
ORR181527Medicare PIN
OR181694Medicaid
ORR144479Medicare PIN