Provider Demographics
NPI:1972584779
Name:COFFMAN, CHARLES BRIAN (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:BRIAN
Last Name:COFFMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1600 W UNIVERSITY AVE STE 215
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3115
Mailing Address - Country:US
Mailing Address - Phone:928-774-1693
Mailing Address - Fax:928-774-3533
Practice Address - Street 1:1200 N BEAVER ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3118
Practice Address - Country:US
Practice Address - Phone:928-774-1693
Practice Address - Fax:928-774-3533
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA931632083A0100X
AZ50345207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN