Provider Demographics
NPI:1346469616
Name:STAFFORD, JOHN SULLIVAN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:SULLIVAN
Last Name:STAFFORD
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 1:4226 WARPATH AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:TX
Mailing Address - Zip Code:77510-8615
Mailing Address - Country:US
Mailing Address - Phone:409-925-4949
Mailing Address - Fax:409-925-4088
Practice Address - Street 1:4226 WARPATH AVE
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:TX
Practice Address - Zip Code:77510-8615
Practice Address - Country:US
Practice Address - Phone:409-925-4949
Practice Address - Fax:409-925-4088
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG5640208D00000X
TXPA00750363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Not Answered363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC22165Medicare UPIN
TX00FS50Medicare ID - Type Unspecified