Provider Demographics
NPI:1134104474
Name:STAFFORD, LYNN H (DPM)
Entity Type:Individual
Prefix:DR
First Name:LYNN
Middle Name:H
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7559 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4131
Mailing Address - Country:US
Mailing Address - Phone:260-436-3579
Mailing Address - Fax:260-459-0287
Practice Address - Street 1:7559 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4131
Practice Address - Country:US
Practice Address - Phone:260-436-3579
Practice Address - Fax:260-459-0287
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000636213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN136760BMedicare PIN