Provider Demographics
NPI:1265774533
Name:KOFAHL, ANDRA (MD)
Entity type:Individual
Prefix:
First Name:ANDRA
Middle Name:
Last Name:KOFAHL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 JENNY GEORGE LANE
Mailing Address - Street 2:BUILDING A, SUITE E
Mailing Address - City:SWEETWATER
Mailing Address - State:TX
Mailing Address - Zip Code:79556
Mailing Address - Country:US
Mailing Address - Phone:325-235-1942
Mailing Address - Fax:
Practice Address - Street 1:2301 W WHITE AVE
Practice Address - Street 2:611
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75071-3119
Practice Address - Country:US
Practice Address - Phone:262-989-7856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-25
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPROVISIONAL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine