Provider Demographics
NPI:1245272400
Name:STAFFORD, GARY LEE (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:LEE
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 1:1400 ANTIOCH CHURCH RD W
Mailing Address - Street 2:
Mailing Address - City:LENOIR CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37772-5009
Mailing Address - Country:US
Mailing Address - Phone:865-986-4120
Mailing Address - Fax:
Practice Address - Street 1:550 FORT LOUDOUN MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:LENOIR CITY
Practice Address - State:TN
Practice Address - Zip Code:37772-5673
Practice Address - Country:US
Practice Address - Phone:865-271-6035
Practice Address - Fax:865-271-6262
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN27430207P00000X
TNBS4671966207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3098382Medicaid
TN3079249OtherBLUE CROSS
TN3098382Medicaid