Provider Demographics
NPI:1619978707
Name:STANIFORTH, MARK E (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:STANIFORTH
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 1:1250 MERCY DR
Mailing Address - Street 2:STE 101
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-1881
Mailing Address - Country:US
Mailing Address - Phone:231-733-1912
Mailing Address - Fax:
Practice Address - Street 1:1250 MERCY DR
Practice Address - Street 2:STE 101
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1881
Practice Address - Country:US
Practice Address - Phone:231-739-6375
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-10
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5315016730207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4625118Medicaid
MII07062Medicare UPIN