Provider Demographics
NPI:1841200821
Name:KOFENDER, MARVIN L (MD)
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:L
Last Name:KOFENDER
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 1:8340 LAKEWOOD RANCH BLVD
Mailing Address - Street 2:SUITE 350
Mailing Address - City:LAKEWOOD RANCH
Mailing Address - State:FL
Mailing Address - Zip Code:34202
Mailing Address - Country:US
Mailing Address - Phone:941-907-0588
Mailing Address - Fax:941-373-6622
Practice Address - Street 1:8340 LAKEWOOD RANCH BLVD
Practice Address - Street 2:SUITE 350
Practice Address - City:LAKEWOOD RANCH
Practice Address - State:FL
Practice Address - Zip Code:34202
Practice Address - Country:US
Practice Address - Phone:941-907-0588
Practice Address - Fax:941-373-6622
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMK027675207R00000X
FLME83376207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIC1649OtherMCARE
MIP118047OtherCARE CHOICES
MI110F374710OtherBCBS
MI102105736Medicaid
FL280556100Medicaid
FL280556100Medicaid
MIC1649OtherMCARE
B44205Medicare UPIN