Healthcare Provider Details

I. General information

NPI: 1124550686
Provider Name (Legal Business Name): BILL STAFFORD, M.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2017
Last Update Date: 04/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 N KENTUCKY AVE
WEST PLAINS MO
65775-2073
US

IV. Provider business mailing address

312 N KENTUCKY AVE
WEST PLAINS MO
65775-2073
US

V. Phone/Fax

Practice location:
  • Phone: 417-257-7076
  • Fax: 417-257-1417
Mailing address:
  • Phone: 417-257-7076
  • Fax: 417-257-1417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR3F13
License Number StateMO

VIII. Authorized Official

Name: DR. BILL W STAFFORD JR.
Title or Position: OWNER
Credential: M.D.
Phone: 417-257-7076