Provider Demographics
NPI:1962436675
Name:STAFFORD, PETER (PT)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:STAFFORD
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 1:11450 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-7106
Mailing Address - Country:US
Mailing Address - Phone:219-488-0157
Mailing Address - Fax:219-661-2502
Practice Address - Street 1:11450 BROADWAY
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-7106
Practice Address - Country:US
Practice Address - Phone:219-488-0157
Practice Address - Fax:219-661-2502
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05006990A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN216000JMedicare PIN