Provider Demographics
NPI:1528064102
Name:STAFFORD, JOSEPH WILLIAM JR
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:WILLIAM
Last Name:STAFFORD
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:BILL
Other - Middle Name:
Other - Last Name:STAFFORD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:312 N KENTUCKY AVE
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775-2073
Mailing Address - Country:US
Mailing Address - Phone:417-257-7076
Mailing Address - Fax:417-257-1417
Practice Address - Street 1:312 N KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-2073
Practice Address - Country:US
Practice Address - Phone:417-257-7076
Practice Address - Fax:417-257-1417
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-28
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR3F132080A0000X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202169405Medicaid
AK108316001Medicare ID - Type UnspecifiedAR MED NO
MO598351302Medicare ID - Type UnspecifiedRURAL HEALTH CLINIC NO
MO202169405Medicaid