Provider Demographics
NPI:1679743413
Name:KOFMAN, GREGORY L (DC)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:L
Last Name:KOFMAN
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 1:11685 MAGNOLIA BLVD
Mailing Address - Street 2:
Mailing Address - City:VALLEY VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91601-3065
Mailing Address - Country:US
Mailing Address - Phone:818-766-8485
Mailing Address - Fax:
Practice Address - Street 1:11685 MAGNOLIA BLVD
Practice Address - Street 2:
Practice Address - City:VALLEY VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91601-3065
Practice Address - Country:US
Practice Address - Phone:818-766-8485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-07
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC20670111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC20670Medicare PIN