Healthcare Provider Details

I. General information

NPI: 1508842261
Provider Name (Legal Business Name): STAFFORD D JOHN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2005
Last Update Date: 12/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3435 70TH ST
JACKSON HEIGHTS NY
11372-1055
US

IV. Provider business mailing address

723 REMSEN AVE
BROOKLYN NY
11236-1227
US

V. Phone/Fax

Practice location:
  • Phone: 718-651-9700
  • Fax: 718-533-0264
Mailing address:
  • Phone: 718-345-9106
  • Fax: 718-533-0264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number020469
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number020469
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: