Provider Demographics
NPI:1023231420
Name:KOFOED, LAVAR W (OD)
Entity type:Individual
Prefix:DR
First Name:LAVAR
Middle Name:W
Last Name:KOFOED
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:291 N MILWAUKEE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9132
Mailing Address - Country:US
Mailing Address - Phone:208-378-7020
Mailing Address - Fax:208-375-7970
Practice Address - Street 1:291 N MILWAUKEE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9132
Practice Address - Country:US
Practice Address - Phone:208-378-7020
Practice Address - Fax:208-378-9460
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-972152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDU63290Medicare UPIN