Provider Demographics
NPI:1255499513
Name:KOFFLER, JEFFREY MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:MICHAEL
Last Name:KOFFLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 GLENBROOK RD
Mailing Address - Street 2:1G
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-2968
Mailing Address - Country:US
Mailing Address - Phone:203-323-2500
Mailing Address - Fax:203-323-3003
Practice Address - Street 1:39 GLENBROOK RD
Practice Address - Street 2:1G
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-2968
Practice Address - Country:US
Practice Address - Phone:203-323-2500
Practice Address - Fax:203-323-3003
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0217602084P0800X
NY1371142084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001217603Medicaid
56010021760CT1OtherBLUE CROSS BLUE SHIELD
033247OtherMHN
P1082129OtherOXFORD HEALTH PLAN
CT260000665Medicare ID - Type Unspecified
CT001217603Medicaid