Provider Demographics
NPI:1164480166
Name:STAFFORD, SAM III (MD)
Entity Type:Individual
Prefix:DR
First Name:SAM
Middle Name:
Last Name:STAFFORD
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:570 LONG POINT RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-7930
Mailing Address - Country:US
Mailing Address - Phone:843-881-0320
Mailing Address - Fax:843-881-5453
Practice Address - Street 1:570 LONG POINT RD
Practice Address - Street 2:SUITE 200
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-7930
Practice Address - Country:US
Practice Address - Phone:843-881-0320
Practice Address - Fax:843-881-5453
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC570943516174400000X
SC08579207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC085794Medicaid
SCC60581Medicare UPIN
SC7818Medicare PIN