Provider Demographics
NPI:1639267362
Name:BRUCE A. STAFFORD, DO, PC
Entity type:Organization
Organization Name:BRUCE A. STAFFORD, DO, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:STAFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:405-390-4280
Mailing Address - Street 1:15809 NE 23RD ST
Mailing Address - Street 2:
Mailing Address - City:CHOCTAW
Mailing Address - State:OK
Mailing Address - Zip Code:73020-8428
Mailing Address - Country:US
Mailing Address - Phone:405-390-4280
Mailing Address - Fax:405-390-4282
Practice Address - Street 1:15809 NE 23RD ST
Practice Address - Street 2:
Practice Address - City:CHOCTAW
Practice Address - State:OK
Practice Address - Zip Code:73020-8428
Practice Address - Country:US
Practice Address - Phone:405-390-4280
Practice Address - Fax:405-390-4282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3919207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200019750AMedicaid
OK100522083Medicare ID - Type UnspecifiedGROUP NUMBER
OKI00757Medicare UPIN