Provider Demographics
NPI:1306805692
Name:STAFFORD, TIMOTHY A (OD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:A
Last Name:STAFFORD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2737 WINNSBORO RD
Mailing Address - Street 2:PO BOX 493
Mailing Address - City:NEWBERRY
Mailing Address - State:SC
Mailing Address - Zip Code:29108-4011
Mailing Address - Country:US
Mailing Address - Phone:803-276-3271
Mailing Address - Fax:803-233-2881
Practice Address - Street 1:2737 WINNSBORO RD
Practice Address - Street 2:
Practice Address - City:NEWBERRY
Practice Address - State:SC
Practice Address - Zip Code:29108-4011
Practice Address - Country:US
Practice Address - Phone:803-276-3271
Practice Address - Fax:803-233-2881
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC696152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD06964Medicaid
SCD06964Medicaid
SCT25013Medicare UPIN
SCT250132929Medicare PIN