Provider Demographics
NPI:1740382670
Name:STAFFORD, OLYMPIA
Entity type:Individual
Prefix:
First Name:OLYMPIA
Middle Name:
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6351 W RIO GRANDE AVE
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-7634
Mailing Address - Country:US
Mailing Address - Phone:509-543-9280
Mailing Address - Fax:509-579-5915
Practice Address - Street 1:6351 W RIO GRANDE AVE
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-7634
Practice Address - Country:US
Practice Address - Phone:509-543-9280
Practice Address - Fax:509-579-5915
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00041509207RI0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1017959Medicaid
WAH69823Medicare UPIN
WA8324378Medicaid