Provider Demographics
NPI:1013975028
Name:STAFFORD, FREDERICK LAMARR (MD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:LAMARR
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 1:701 E 28TH STREET
Mailing Address - Street 2:SUITE 416
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806
Mailing Address - Country:US
Mailing Address - Phone:562-427-1322
Mailing Address - Fax:562-427-2255
Practice Address - Street 1:701 E 28TH STREET
Practice Address - Street 2:SUITE 416
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806
Practice Address - Country:US
Practice Address - Phone:562-427-1322
Practice Address - Fax:562-427-2255
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG57932208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA006579320Medicaid
CA006579320Medicaid
W16893Medicare ID - Type Unspecified