Provider Information for 1669035218
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Dr. IVAN JOHN STANFORD MD
Sex: Male
NPI: 1669035218
Last Updated: 2022-07-01
Certification Date: 2022-07-01
Certification Date: 2022-07-01
Details
| Name | Value | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| NPI | 1669035218 | ||||||||||||
| Enumeration Date | 2019-04-19 | ||||||||||||
| NPI Type | NPI-1 Individual | ||||||||||||
| Sole Proprietor | NO | ||||||||||||
| Status | Active | ||||||||||||
| Mailing Address | 263 FARMINGTON AVE FARMINGTON, CT 06030-8021 United States Phone: 860-679-4477 | Fax:860-679-1025 | ||||||||||||
| Primary Practice Address | 263 FARMINGTON AVE FARMINGTON, CT 06030-8021 United States Phone: 860-679-4477 | Fax:860-679-1025 | ||||||||||||
| Secondary Practice Address(es) | 1000 ASYLUM AVE RM 1004 | ||||||||||||
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