Provider Demographics
NPI:1982609707
Name:KOFFER, DENNIS SHELLY (MD)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:SHELLY
Last Name:KOFFER
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 1:131 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:NC
Mailing Address - Zip Code:27577-3915
Mailing Address - Country:US
Mailing Address - Phone:919-934-5441
Mailing Address - Fax:919-934-0152
Practice Address - Street 1:131 E MARKET ST
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:NC
Practice Address - Zip Code:27577-3915
Practice Address - Country:US
Practice Address - Phone:919-934-5441
Practice Address - Fax:919-934-0152
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9300504208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8942740Medicaid
NC8942740Medicaid
NC2194189CMedicare ID - Type Unspecified
2194189CMedicare PIN