Healthcare Provider Details

I. General information

NPI: 1962765321
Provider Name (Legal Business Name): CLEO DENNIS STAFFORD II M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2012
Last Update Date: 02/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3896 PRINCETON LAKES WAY
ATLANTA GA
30331
US

IV. Provider business mailing address

49 JESSE HILL JR DR SE
ATLANTA GA
30303-3049
US

V. Phone/Fax

Practice location:
  • Phone: 404-489-4444
  • Fax:
Mailing address:
  • Phone: 404-778-1550
  • Fax: 404-778-1557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberMD.35085
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number77937
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: