Basic Information
| Provider Information | |||||||||
| NPI: | 1023014628 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STAFFORD | ||||||||
| FirstName: | CALVIN | ||||||||
| MiddleName: | RANDOLPH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | ONE MEDICAL CENTER BLVD | ||||||||
| Address2: | SUITE 533 | ||||||||
| City: | UPLAND | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190133902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6108741184 | ||||||||
| FaxNumber: | 6108744258 | ||||||||
| Practice Location | |||||||||
| Address1: | ONE MEDICAL CENTER BLVD | ||||||||
| Address2: | SUITE 533 | ||||||||
| City: | UPLAND | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190133902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106197475 | ||||||||
| FaxNumber: | 6106197477 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2005 | ||||||||
| LastUpdateDate: | 11/15/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | MD013709E | PA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 0646325 | 05 | PA | MEDICAID |