Provider Demographics
NPI:1992780878
Name:STAFFORD, WARREN KEITH (MD)
Entity type:Individual
Prefix:DR
First Name:WARREN
Middle Name:KEITH
Last Name:STAFFORD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8055 WERTMAN RD
Mailing Address - Street 2:
Mailing Address - City:FOGELSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18051-1820
Mailing Address - Country:US
Mailing Address - Phone:484-553-3286
Mailing Address - Fax:484-214-0347
Practice Address - Street 1:206A S MAIN ST
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650-2127
Practice Address - Country:US
Practice Address - Phone:864-989-0230
Practice Address - Fax:864-334-1880
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-13
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23690207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC236907Medicaid
E303880281Medicare PIN
SC236907Medicaid