Provider Demographics
NPI:1730182247
Name:STAFFORD, JOHN M (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:STAFFORD
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Gender:M
Credentials:MD
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Mailing Address - Street 1:3800 HOLLYWOOD RD STE 101
Mailing Address - Street 2:ROYALTON MEDICAL CENTER
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-8511
Mailing Address - Country:US
Mailing Address - Phone:269-428-2552
Mailing Address - Fax:269-428-2943
Practice Address - Street 1:3800 HOLLYWOOD RD STE 101
Practice Address - Street 2:ROYALTON MEDICAL CENTER
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-8511
Practice Address - Country:US
Practice Address - Phone:269-428-2552
Practice Address - Fax:269-428-2943
Is Sole Proprietor?:No
Enumeration Date:2005-05-30
Last Update Date:2013-11-27
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Provider Licenses
StateLicense IDTaxonomies
MI4301044515207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI310272010Medicaid
MIB43647Medicare UPIN
MI310272010Medicaid