Healthcare Provider Details

I. General information

NPI: 1831292358
Provider Name (Legal Business Name): JOHN WILEY STAFFORD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 WESTMARK BLVD
LAFAYETTE LA
70506-7365
US

IV. Provider business mailing address

207 WESTMARK BLVD
LAFAYETTE LA
70506-7365
US

V. Phone/Fax

Practice location:
  • Phone: 337-981-6811
  • Fax: 337-981-2024
Mailing address:
  • Phone: 337-981-6811
  • Fax: 337-981-2024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number013845
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: