Basic Information
| Provider Information | |||||||||
| NPI: | 1679571582 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COFFEY | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | PAUL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4500 S GARNETT RD | ||||||||
| Address2: | STE 919 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741465214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053647900 | ||||||||
| FaxNumber: | 4053666214 | ||||||||
| Practice Location | |||||||||
| Address1: | 825 E ROBINSON ST | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730716610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053647900 | ||||||||
| FaxNumber: | 4053666214 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2005 | ||||||||
| LastUpdateDate: | 01/02/2019 | ||||||||
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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 | 174400000X | 10847 | OK | N | Other Service Providers | Specialist | 2085R0202X | 10847 | OK | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 300034744 | 01 | OK | RR MEDICARE | OTHER | 10010020A | 05 | OK | MEDICAID |