Provider Demographics
NPI:1942360813
Name:COFFEY, C. EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:C. EDWARD
Middle Name:
Last Name:COFFEY
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 1:12301 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77035-6207
Mailing Address - Country:US
Mailing Address - Phone:713-275-5007
Mailing Address - Fax:
Practice Address - Street 1:12301 MAIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77035-6207
Practice Address - Country:US
Practice Address - Phone:713-275-5007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ57832084P0800X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CC067622OtherCHAMPUS-CHAMPUS
0822962000Medicare ID - Type Unspecified
CC067622OtherCOMMERCIAL-COMMERCIAL NUMBER
2708229621OtherBLUE CROSS-BLUE CROSS
C87585Medicare UPIN