Healthcare Provider Details

I. General information

NPI: 1366480790
Provider Name (Legal Business Name): JERALD R STAFFORD MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 10/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24411 HEALTH CENTER DR SUITE 560
LAGUNA HILLS CA
92653
US

IV. Provider business mailing address

24411 HEALTH CENTER DR SUITE 560
LAGUNA HILLS CA
92653
US

V. Phone/Fax

Practice location:
  • Phone: 949-458-1223
  • Fax: 949-588-7572
Mailing address:
  • Phone: 949-458-1223
  • Fax: 949-588-7572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberA25139
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberA25139
License Number StateCA

VIII. Authorized Official

Name: JERALD ROBERT STAFFORD
Title or Position: PRESIDENT
Credential: MD
Phone: 949-458-1223