Provider Demographics
NPI:1942339429
Name:KOFKOFF, RICHARD L (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:L
Last Name:KOFKOFF
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 1:16216 BAXTER RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-4770
Mailing Address - Country:US
Mailing Address - Phone:636-532-1717
Mailing Address - Fax:636-532-5782
Practice Address - Street 1:16216 BAXTER RD
Practice Address - Street 2:SUITE 250
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-4770
Practice Address - Country:US
Practice Address - Phone:636-532-1717
Practice Address - Fax:636-532-5782
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6G32208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOA12874Medicare UPIN