Provider Demographics
NPI:1326094715
Name:STANFORD, EDWARD JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:JOSEPH
Last Name:STANFORD
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 1:1262 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-4962
Mailing Address - Country:US
Mailing Address - Phone:209-823-7646
Mailing Address - Fax:209-824-5374
Practice Address - Street 1:1262 E NORTH ST
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336
Practice Address - Country:US
Practice Address - Phone:209-823-7646
Practice Address - Fax:209-824-5374
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036080278207VG0400X, 208600000X
CA59064207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036080278Medicaid
IL212529OtherGROUP MEDICARE #
ILE47082Medicare UPIN