Provider Demographics
NPI:1104074699
Name:STAFFORD, CHARLES TANNER (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:TANNER
Last Name:STAFFORD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 N. DONALSON ST.
Mailing Address - Street 2:SUITE B
Mailing Address - City:BAINBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:39817
Mailing Address - Country:US
Mailing Address - Phone:229-220-0780
Mailing Address - Fax:
Practice Address - Street 1:119 N. DONALSON ST.
Practice Address - Street 2:SUITE B
Practice Address - City:BAINBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:39817
Practice Address - Country:US
Practice Address - Phone:229-220-0780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-09
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA017767207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D42298Medicare UPIN