Basic Information
| Provider Information | |||||||||
| NPI: | 1205870482 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COFFLER | ||||||||
| FirstName: | MICKEY | ||||||||
| MiddleName: | SEMO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 WEST ARBOR DRIVE MC 8201 | ||||||||
| Address2: | UCSD MEDICAL CENTER | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921038201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8586578745 | ||||||||
| FaxNumber: | 6195433183 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 WEST ARBOR DRIVE MC 8201 | ||||||||
| Address2: | UCSD MEDICAL CENTER | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921038201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8586578745 | ||||||||
| FaxNumber: | 6195433183 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | A73812 | CA | X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207VE0102X | A73812 | CA | X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Reproductive Endocrinology |
ID Information
| ID | Type | State | Issuer | Description | 00A738120 | 05 | CA | MEDICAID |