Provider Demographics
NPI:1902967797
Name:TRAVIS, STANLEY J JR (DO)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:J
Last Name:TRAVIS
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 BUCKMAN DRIVE
Mailing Address - Street 2:
Mailing Address - City:HATBORO
Mailing Address - State:PA
Mailing Address - Zip Code:19040-1402
Mailing Address - Country:US
Mailing Address - Phone:215-672-6878
Mailing Address - Fax:215-672-6812
Practice Address - Street 1:501 BUCKMAN DRIVE
Practice Address - Street 2:
Practice Address - City:HATBORO
Practice Address - State:PA
Practice Address - Zip Code:19040-1402
Practice Address - Country:US
Practice Address - Phone:215-672-6878
Practice Address - Fax:215-672-6812
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0S002173L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0060654401OtherMEDICAL ASSISTANCE
TR041691Medicare ID - Type Unspecified
D66278Medicare UPIN