Provider Demographics
NPI:1619991494
Name:STAFFORD, DALE D (MD)
Entity Type:Individual
Prefix:DR
First Name:DALE
Middle Name:D
Last Name:STAFFORD
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 1:168 GRANDVIEW TER
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:VT
Mailing Address - Zip Code:05602-8431
Mailing Address - Country:US
Mailing Address - Phone:802-223-0423
Mailing Address - Fax:
Practice Address - Street 1:130 FISHER RD
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:VT
Practice Address - Zip Code:05602-9516
Practice Address - Country:US
Practice Address - Phone:802-225-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT420006939207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01777706Medicaid
VT0005471Medicaid
NY01777706Medicaid
VTB85529Medicare UPIN