Provider Demographics
NPI:1023142817
Name:STAFFORD, GEORGE TIMOTHY III (MD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:TIMOTHY
Last Name:STAFFORD
Suffix:III
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 1:5800 BLUE SPRUCE AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMOSA
Mailing Address - State:CO
Mailing Address - Zip Code:81101-9738
Mailing Address - Country:US
Mailing Address - Phone:719-589-0371
Mailing Address - Fax:719-589-0371
Practice Address - Street 1:5800 BLUE SPRUCE AVE
Practice Address - Street 2:
Practice Address - City:ALAMOSA
Practice Address - State:CO
Practice Address - Zip Code:81101-9738
Practice Address - Country:US
Practice Address - Phone:719-589-0371
Practice Address - Fax:719-589-0371
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2009-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO37393208600000X
AL3542208600000X
WY3235A208600000X
MT8440208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01373935Medicaid
MT0149702Medicaid
COE37369Medicare UPIN
CO020040321Medicare ID - Type Unspecified
CO01373935Medicaid
MT0149702Medicaid
MT000071889Medicare Oscar/Certification