Provider Demographics
NPI:1700826534
Name:STAFFORD, BIC (DPM)
Entity Type:Individual
Prefix:
First Name:BIC
Middle Name:
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11352 DORSETT RD
Mailing Address - Street 2:
Mailing Address - City:MARYLAND HEIGHTS
Mailing Address - State:MO
Mailing Address - Zip Code:63043-3412
Mailing Address - Country:US
Mailing Address - Phone:314-289-8777
Mailing Address - Fax:
Practice Address - Street 1:11352 DORSETT RD
Practice Address - Street 2:
Practice Address - City:MARYLAND HEIGHTS
Practice Address - State:MO
Practice Address - Zip Code:63043-3412
Practice Address - Country:US
Practice Address - Phone:314-289-8777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000713213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO308544105Medicaid
MOU62419Medicare UPIN
MO308544105Medicaid