Provider Demographics
NPI:1366480790
Name:JERALD R STAFFORD MD INC
Entity Type:Organization
Organization Name:JERALD R STAFFORD MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JERALD
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:STAFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-458-1223
Mailing Address - Street 1:24411 HEALTH CENTER DR
Mailing Address - Street 2:SUITE 560
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653
Mailing Address - Country:US
Mailing Address - Phone:949-458-1223
Mailing Address - Fax:949-588-7572
Practice Address - Street 1:24411 HEALTH CENTER DR
Practice Address - Street 2:SUITE 560
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653
Practice Address - Country:US
Practice Address - Phone:949-458-1223
Practice Address - Fax:949-588-7572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA25139207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Single Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW21073OtherMEDICARE GROUP PTAN
CA00A251390Medicaid
A24298Medicare UPIN
CAW21073OtherMEDICARE GROUP PTAN