Provider Demographics
NPI:1285349894
Name:STAFFORD, JAMES DALE
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:DALE
Last Name:STAFFORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 MARTIN LUTHER KING BLVD
Mailing Address - Street 2:
Mailing Address - City:WAGONER
Mailing Address - State:OK
Mailing Address - Zip Code:74467-6928
Mailing Address - Country:US
Mailing Address - Phone:918-201-4333
Mailing Address - Fax:
Practice Address - Street 1:1101 S MILL ST
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-2954
Practice Address - Country:US
Practice Address - Phone:918-353-3701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-18
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist