Provider Demographics
NPI:1801553110
Name:KOFNOVEC, MARIE MACARAEG (COTA)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:MACARAEG
Last Name:KOFNOVEC
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5724 HUNTERS BEND LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75249-2303
Mailing Address - Country:US
Mailing Address - Phone:972-408-7012
Mailing Address - Fax:
Practice Address - Street 1:630 STONEGLEN DR STE B
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-3626
Practice Address - Country:US
Practice Address - Phone:817-734-6515
Practice Address - Fax:817-717-8584
Is Sole Proprietor?:No
Enumeration Date:2021-11-22
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX224Z00000X2080P0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX464765OtherCOTA