Provider Demographics
NPI:1831292358
Name:STAFFORD, JOHN WILEY (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WILEY
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 1:207 WESTMARK BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-7365
Mailing Address - Country:US
Mailing Address - Phone:337-981-6811
Mailing Address - Fax:337-981-2024
Practice Address - Street 1:207 WESTMARK BLVD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-7365
Practice Address - Country:US
Practice Address - Phone:337-981-6811
Practice Address - Fax:337-981-2024
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA013845208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1171000Medicaid
LA1171000Medicaid
LA6632Medicare ID - Type Unspecified
B65913Medicare UPIN