Provider Demographics
NPI:1255494159
Name:JOE, STANTON HENRY (MD)
Entity Type:Individual
Prefix:DR
First Name:STANTON
Middle Name:HENRY
Last Name:JOE
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 1:1809 VERDUGO BLVD
Mailing Address - Street 2:100
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208-1402
Mailing Address - Country:US
Mailing Address - Phone:818-790-9300
Mailing Address - Fax:818-790-4564
Practice Address - Street 1:1809 VERDUGO BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91208-1402
Practice Address - Country:US
Practice Address - Phone:818-242-1133
Practice Address - Fax:818-242-3658
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG22870174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G228720Medicaid
CA00G228721Medicaid
CAA41752Medicare UPIN
CAW16106AMedicare PIN
CA00G228720Medicaid
CAWG22872JMedicare PIN