Provider Demographics
NPI:1356338487
Name:KOFFEL, KEVIN K (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:K
Last Name:KOFFEL
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 1:3439 GRANITE CIR
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43617-1161
Mailing Address - Country:US
Mailing Address - Phone:419-843-7996
Mailing Address - Fax:419-841-7725
Practice Address - Street 1:3439 GRANITE CIR
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43617-1161
Practice Address - Country:US
Practice Address - Phone:419-843-7996
Practice Address - Fax:419-841-7725
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35045739K207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
4037439OtherAETNA
00267OtherPARAMOUNT
OH0479781Medicaid
P00659824OtherRAILROAD MEDICARE
000000581405OtherANTHEM
OH0479781Medicaid
00267OtherPARAMOUNT
4037439OtherAETNA
OH0500953Medicare ID - Type Unspecified