Provider Demographics
NPI:1386888667
Name:STAUFFER, RICHARD WAYNE (PT)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:WAYNE
Last Name:STAUFFER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7425 MISSION VALLEY RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-4409
Mailing Address - Country:US
Mailing Address - Phone:619-291-3400
Mailing Address - Fax:
Practice Address - Street 1:7425 MISSION VALLEY RD
Practice Address - Street 2:SUITE 201
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4409
Practice Address - Country:US
Practice Address - Phone:619-291-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-30
Last Update Date:2009-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35486225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW17215Medicare PIN
CABV218ZMedicare PIN