Provider Demographics
NPI:1609360890
Name:STAFFORD, ALICIA MARIE (MD)
Entity type:Individual
Prefix:MRS
First Name:ALICIA
Middle Name:MARIE
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:ALICIA
Other - Middle Name:MARIE
Other - Last Name:ANAST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:680 CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-3308
Mailing Address - Country:US
Mailing Address - Phone:508-941-7000
Mailing Address - Fax:
Practice Address - Street 1:680 CENTRE ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-3308
Practice Address - Country:US
Practice Address - Phone:508-941-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-20
Last Update Date:2025-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01089757A2086S0129X
MA10251662086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100897790Medicaid
IN300075440Medicaid
IN01089757AOtherINDIANA STATE LICENSE
IN01089757BOtherCSR