Provider Demographics
NPI:1578821625
Name:KOFENDER, VICKI SANDRA (MD)
Entity type:Individual
Prefix:
First Name:VICKI
Middle Name:SANDRA
Last Name:KOFENDER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18320 ABERDEEN RD.
Mailing Address - Street 2:
Mailing Address - City:STILWELL
Mailing Address - State:KS
Mailing Address - Zip Code:66085
Mailing Address - Country:US
Mailing Address - Phone:816-223-3528
Mailing Address - Fax:
Practice Address - Street 1:8320 ABERDEEN RD
Practice Address - Street 2:
Practice Address - City:STILWELL
Practice Address - State:KS
Practice Address - Zip Code:66085
Practice Address - Country:US
Practice Address - Phone:816-223-3528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-26
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-19583207Q00000X
MO1999142854207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine