Provider Demographics
NPI:1508831009
Name:STAFFORD, RICHARD J
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:J
Last Name:STAFFORD
Suffix:
Gender:M
Credentials:
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 14909
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-0909
Mailing Address - Country:US
Mailing Address - Phone:612-870-5557
Mailing Address - Fax:612-870-5857
Practice Address - Street 1:2550 UNIVERSITY AVE W
Practice Address - Street 2:SUITE 423 SOUTH
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1052
Practice Address - Country:US
Practice Address - Phone:612-870-5557
Practice Address - Fax:612-870-5857
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN263522080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNRR PTAN P00143916Medicare PIN
MNA96295Medicare UPIN