Provider Demographics
NPI:1659465615
Name:STANDEFER, JAMES EARL JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:EARL
Last Name:STANDEFER
Suffix:JR
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:PO BOX 4
Mailing Address - Street 2:
Mailing Address - City:TIVOLI
Mailing Address - State:NY
Mailing Address - Zip Code:12583-0004
Mailing Address - Country:US
Mailing Address - Phone:845-757-2160
Mailing Address - Fax:
Practice Address - Street 1:5 OLD FARM RD
Practice Address - Street 2:SUITE C2
Practice Address - City:RED HOOK
Practice Address - State:NY
Practice Address - Zip Code:12571-1643
Practice Address - Country:US
Practice Address - Phone:845-702-3487
Practice Address - Fax:845-520-9169
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY235444-12084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03038479OtherMEDICAID PROVIDER ID
NY03038479OtherMEDICAID PROVIDER ID