Provider Demographics
NPI:1851663124
Name:DAFFODIL PEDIATRICS AND FAMILY MEDICINE
Entity type:Organization
Organization Name:DAFFODIL PEDIATRICS AND FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:FREDERICK
Authorized Official - Last Name:STACHELRODT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-429-8614
Mailing Address - Street 1:4905 COURTNEY DRIVE
Mailing Address - Street 2:
Mailing Address - City:FOREST PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30297
Mailing Address - Country:US
Mailing Address - Phone:404-366-3636
Mailing Address - Fax:404-362-0808
Practice Address - Street 1:4905 COURTNEY DRIVE
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:GA
Practice Address - Zip Code:30297
Practice Address - Country:US
Practice Address - Phone:404-366-3636
Practice Address - Fax:404-362-0808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-02
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty