Healthcare Provider Details

I. General information

NPI: 1396735759
Provider Name (Legal Business Name): PAUL R STAFFORD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 05/05/2022
Certification Date: 05/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1811 E BERT KOUNS INDUSTRIAL LOOP STE 210
SHREVEPORT LA
71105-5740
US

IV. Provider business mailing address

1811 E BERT KOUNS INDUSTRIAL LOOP STE 210
SHREVEPORT LA
71105-5740
US

V. Phone/Fax

Practice location:
  • Phone: 318-212-3858
  • Fax: 318-212-3958
Mailing address:
  • Phone: 318-212-3858
  • Fax: 318-212-3958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberMD.022010
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD.022010
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: