Provider Demographics
NPI:1972206092
Name:KOFOED, BENJAMIN BRUCE
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:BRUCE
Last Name:KOFOED
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4603 MINNEHAHA AVE UNIT 526
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406-4279
Mailing Address - Country:US
Mailing Address - Phone:952-807-7305
Mailing Address - Fax:
Practice Address - Street 1:49 JESSE HILL JR DR SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-3049
Practice Address - Country:US
Practice Address - Phone:404-778-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program