Provider Demographics
NPI:1972681021
Name:KOFOED, KENNETH R (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:KOFOED
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:PO BOX 786
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-0786
Mailing Address - Country:US
Mailing Address - Phone:801-771-3024
Mailing Address - Fax:
Practice Address - Street 1:1660 W ANTELOPE DR
Practice Address - Street 2:SUIT 115
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-1156
Practice Address - Country:US
Practice Address - Phone:801-771-3024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7423174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist