Provider Demographics
NPI:1578525085
Name:STANFORD, ROYCE ALLAN JR (MD)
Entity Type:Individual
Prefix:
First Name:ROYCE
Middle Name:ALLAN
Last Name:STANFORD
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:R.
Other - Middle Name:ALLAN
Other - Last Name:STANFORD
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2301 SPRINGHILL RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-7552
Mailing Address - Country:US
Mailing Address - Phone:501-315-0078
Mailing Address - Fax:501-943-3016
Practice Address - Street 1:2301 SPRINGHILL RD
Practice Address - Street 2:SUITE 200
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-7552
Practice Address - Country:US
Practice Address - Phone:501-315-0078
Practice Address - Fax:501-943-3016
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-5980208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR105904001Medicaid
AR55089OtherBCBS NUMBER
AR11300000000OtherQUALCHOICE PROVIDER ID
AR1220097OtherUNITED HEALTHCARE PROV #
AR4203731OtherAETNA PROVIDER ID
AR11300000000OtherQUALCHOICE PROVIDER ID