Provider Demographics
NPI:1821433053
Name:KOFFER, PAUL P (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:P
Last Name:KOFFER
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 1:800 WASHINGTON ST.
Mailing Address - Street 2:BOX 1013: PROVIDER ENROLLMENT
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-1552
Mailing Address - Country:US
Mailing Address - Phone:617-636-8153
Mailing Address - Fax:617-636-1465
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903
Practice Address - Country:US
Practice Address - Phone:401-444-3600
Practice Address - Fax:401-444-3124
Is Sole Proprietor?:No
Enumeration Date:2013-05-01
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD161862085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1821433053Medicaid