Provider Demographics
NPI:1285631598
Name:STANFORD, MARIE TERESA (MD)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:TERESA
Last Name:STANFORD
Suffix:
Gender:F
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:PO BOX 577
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:WA
Mailing Address - Zip Code:98944-0577
Mailing Address - Country:US
Mailing Address - Phone:509-837-6911
Mailing Address - Fax:509-837-6920
Practice Address - Street 1:803 E LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:WA
Practice Address - Zip Code:98944-2383
Practice Address - Country:US
Practice Address - Phone:509-837-6911
Practice Address - Fax:509-837-6920
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00029777207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAF48956Medicare UPIN