Provider Demographics
NPI:1760423735
Name:COFFMAN, DEREK DURRELL (DC)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:DURRELL
Last Name:COFFMAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3515 E 31ST ST STE B
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-1520
Mailing Address - Country:US
Mailing Address - Phone:918-749-4263
Mailing Address - Fax:866-543-9680
Practice Address - Street 1:3515 E 31ST ST STE B
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-1520
Practice Address - Country:US
Practice Address - Phone:918-749-4263
Practice Address - Fax:866-543-9680
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3472111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK3472OtherCHIROPRACTIC LICENSE
OKU99552Medicare UPIN
OK241416106Medicare PIN
OK100522121Medicare PIN