Basic Information
| Provider Information | |||||||||
| NPI: | 1033179684 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COFAS INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2218 SHALLOCK AVE | ||||||||
| Address2: | |||||||||
| City: | KLAMATH FALLS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976014290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418823818 | ||||||||
| FaxNumber: | 5418829800 | ||||||||
| Practice Location | |||||||||
| Address1: | 2218 SHALLOCK AVE | ||||||||
| Address2: | |||||||||
| City: | KLAMATH FALLS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976014290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418823818 | ||||||||
| FaxNumber: | 5418829800 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2006 | ||||||||
| LastUpdateDate: | 05/16/2019 | ||||||||
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| AuthorizedOfficialLastName: | COFAS | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | KEITH | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/MD | ||||||||
| AuthorizedOfficialTelephone: | 5418823818 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD11585 | OR | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 363A00000X | PA01446 | OR | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207R00000X | MD25846 | OR | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 027754 | 05 | OR | MEDICAID | DE8224 | 01 | OR | RAILROAD MEDICARE | OTHER |