Provider Demographics
NPI:1174527600
Name:PRESCOTT, STANFORD T JR (MD)
Entity type:Individual
Prefix:
First Name:STANFORD
Middle Name:T
Last Name:PRESCOTT
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:STANFORD
Other - Middle Name:T
Other - Last Name:PRESCOTT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1001 CAMDEN CT
Mailing Address - Street 2:
Mailing Address - City:WOODWAY
Mailing Address - State:TX
Mailing Address - Zip Code:76712-8566
Mailing Address - Country:US
Mailing Address - Phone:253-678-9830
Mailing Address - Fax:
Practice Address - Street 1:1001 CAMDEN CT
Practice Address - Street 2:
Practice Address - City:WOODWAY
Practice Address - State:TX
Practice Address - Zip Code:76712-8566
Practice Address - Country:US
Practice Address - Phone:253-678-9830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00030232207L00000X
IN01070563A207L00000X
OK30862207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1118132Medicaid
WAG8801176Medicare ID - Type Unspecified
H42957Medicare UPIN