Provider Demographics
NPI:1689774085
Name:STANFORTH, SHELLEY A (MD)
Entity Type:Individual
Prefix:DR
First Name:SHELLEY
Middle Name:A
Last Name:STANFORTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 NUNNER RD.
Mailing Address - Street 2:
Mailing Address - City:MAINEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45039
Mailing Address - Country:US
Mailing Address - Phone:513-677-2405
Mailing Address - Fax:513-677-2781
Practice Address - Street 1:67 NUNNER RD
Practice Address - Street 2:
Practice Address - City:MAINEVILLE
Practice Address - State:OH
Practice Address - Zip Code:45039
Practice Address - Country:US
Practice Address - Phone:513-677-2405
Practice Address - Fax:513-677-2781
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-065438207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2032606Medicaid
OH36-06-5438OtherSTATE LICENSE
OH36-06-5438OtherSTATE LICENSE
OHG58908Medicare UPIN