Provider Demographics
NPI:1508842261
Name:JOHN, STAFFORD D (MD)
Entity Type:Individual
Prefix:MR
First Name:STAFFORD
Middle Name:D
Last Name:JOHN
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 1:723 REMSEN AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-1227
Mailing Address - Country:US
Mailing Address - Phone:718-345-9106
Mailing Address - Fax:718-533-0264
Practice Address - Street 1:3435 70TH ST
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-1055
Practice Address - Country:US
Practice Address - Phone:718-651-9700
Practice Address - Fax:718-533-0264
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-15
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
173000000X
NY020469174400000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No173000000XOther Service ProvidersLegal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01918556Medicaid
H66066Medicare UPIN
05309Medicare ID - Type Unspecified