Provider Demographics
NPI:1932227196
Name:HOFFERTH, GERARD GORDON (DC)
Entity Type:Individual
Prefix:DR
First Name:GERARD
Middle Name:GORDON
Last Name:HOFFERTH
Suffix:
Gender:M
Credentials:DC
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 6206
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46660-6206
Mailing Address - Country:US
Mailing Address - Phone:574-256-1008
Mailing Address - Fax:574-256-9088
Practice Address - Street 1:826 W EDISON RD
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-2744
Practice Address - Country:US
Practice Address - Phone:574-256-1008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001419111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN5547648OtherAETNA ID#
IN100093260AMedicaid
IN000000089658OtherBLUE CROSS BLUE SHIELD ID
IN000000089658OtherBLUE CROSS BLUE SHIELD ID
IN100093260AMedicaid