Provider Demographics
NPI:1063502318
Name:STAFFORD, BENJAMIN THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:THOMAS
Last Name:STAFFORD
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 1:612 W DUARTE RD
Mailing Address - Street 2:SUITE 304
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91007-7602
Mailing Address - Country:US
Mailing Address - Phone:626-446-4461
Mailing Address - Fax:626-445-0647
Practice Address - Street 1:612 W DUARTE RD
Practice Address - Street 2:SUITE 304
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91007-7602
Practice Address - Country:US
Practice Address - Phone:626-446-4461
Practice Address - Fax:626-445-0647
Is Sole Proprietor?:No
Enumeration Date:2006-10-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG19825207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAYYY48961YMedicaid
CAG19825OtherSTATE MEDICAL LICENSE NUM
CAYYY48961YOtherBLUE SHIELD OF CALIF GR N
CAW2154Medicare ID - Type UnspecifiedGROUP ID NUMBER
CAA40766Medicare UPIN
CAYYY48961YMedicaid