Basic Information
| Provider Information | |||||||||
| NPI: | 1841200821 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOFENDER | ||||||||
| FirstName: | MARVIN | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 8340 LAKEWOOD RANCH BLVD | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | LAKEWOOD RANCH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9419070588 | ||||||||
| FaxNumber: | 9413736622 | ||||||||
| Practice Location | |||||||||
| Address1: | 8340 LAKEWOOD RANCH BLVD | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | LAKEWOOD RANCH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9419070588 | ||||||||
| FaxNumber: | 9413736622 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 05/12/2010 | ||||||||
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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 | 207R00000X | MK027675 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | ME83376 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | C1649 | 01 | MI | MCARE | OTHER | P118047 | 01 | MI | CARE CHOICES | OTHER | 110F374710 | 01 | MI | BCBS | OTHER | 102105736 | 05 | MI | MEDICAID | 280556100 | 05 | FL | MEDICAID |