Provider Demographics
NPI:1275428435
Name:STAFFORD, SCOTT DAVID (MA87096)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:DAVID
Last Name:STAFFORD
Suffix:
Gender:M
Credentials:MA87096
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 WEDGEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-7718
Mailing Address - Country:US
Mailing Address - Phone:386-276-6163
Mailing Address - Fax:
Practice Address - Street 1:1240 S OCEAN SHORE BLVD
Practice Address - Street 2:
Practice Address - City:FLAGLER BEACH
Practice Address - State:FL
Practice Address - Zip Code:32136-3703
Practice Address - Country:US
Practice Address - Phone:386-276-6163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-10
Last Update Date:2025-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA87096225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist