Provider Demographics
NPI:1639171499
Name:STANFORD, JOHN R (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:STANFORD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:2414 E STATE BLVD
Mailing Address - Street 2:CAREW BUILDING #1, SUITE 201
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-4760
Mailing Address - Country:US
Mailing Address - Phone:260-482-4741
Mailing Address - Fax:260-482-3051
Practice Address - Street 1:2414 E STATE BLVD
Practice Address - Street 2:CAREW BUILDING #1, SUITE 201
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4760
Practice Address - Country:US
Practice Address - Phone:260-482-4741
Practice Address - Fax:260-482-3051
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01028422A208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN149080JMedicare ID - Type Unspecified
IND95279Medicare UPIN