Healthcare Provider Details

I. General information

NPI: 1356757991
Provider Name (Legal Business Name): MICHAEL TRACE STAFFORD D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2014
Last Update Date: 08/05/2020
Certification Date: 08/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1123 BELLEVILLE AVE
BREWTON AL
36426-1505
US

IV. Provider business mailing address

1123 BELLEVILLE AVE
BREWTON AL
36426-1505
US

V. Phone/Fax

Practice location:
  • Phone: 251-867-8001
  • Fax: 251-867-9643
Mailing address:
  • Phone: 251-867-8001
  • Fax: 251-867-9643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberDO.2013
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: