Provider Demographics
NPI:1003003187
Name:FREDERICK L.STAFFORD M.D., INC.
Entity Type:Organization
Organization Name:FREDERICK L.STAFFORD M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:L
Authorized Official - Last Name:STAFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-427-1322
Mailing Address - Street 1:701 E 28TH ST
Mailing Address - Street 2:411
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-2759
Mailing Address - Country:US
Mailing Address - Phone:562-427-1322
Mailing Address - Fax:
Practice Address - Street 1:701 E 28TH ST
Practice Address - Street 2:411
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-2759
Practice Address - Country:US
Practice Address - Phone:562-427-1322
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-02
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG57932146D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes146D00000XEmergency Medical Service ProvidersPersonal Emergency Response AttendantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G579320Medicaid
CAF01284Medicare UPIN