Provider Demographics
NPI:1184633307
Name:WALKER, STANFORD LEE (MD)
Entity Type:Individual
Prefix:
First Name:STANFORD
Middle Name:LEE
Last Name:WALKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1869 BRENTWOOD RD
Mailing Address - Street 2:365 EAST MAIN ST
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-4625
Mailing Address - Country:US
Mailing Address - Phone:631-416-5480
Mailing Address - Fax:631-994-2900
Practice Address - Street 1:SOUTH BROOKHAVEN HEALTH CENTER
Practice Address - Street 2:365 EAST MAIN ST
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772
Practice Address - Country:US
Practice Address - Phone:631-854-1307
Practice Address - Fax:631-854-1310
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2017-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY180556207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01153171Medicaid
NY01153171Medicaid
E44940Medicare UPIN