Provider Demographics
NPI:1952500415
Name:STADDON, JACK (MD, PHD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:STADDON
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3243 E MURDOCK ST STE 510
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-3007
Mailing Address - Country:US
Mailing Address - Phone:316-962-3928
Mailing Address - Fax:
Practice Address - Street 1:3243 E MURDOCK ST STE 510
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67208-3007
Practice Address - Country:US
Practice Address - Phone:316-962-3928
Practice Address - Fax:316-962-3930
Is Sole Proprietor?:No
Enumeration Date:2007-07-15
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KS04-458152080P0207X
UT7766460-89052080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology