Healthcare Provider Details

I. General information

NPI: 1609952332
Provider Name (Legal Business Name): ANDY J. STAFFORD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 12/23/2020
Certification Date: 12/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2920 MCINTYRE DR SUITE 250
BLOOMINGTON IN
47403-4221
US

IV. Provider business mailing address

PO BOX 1329
BLOOMINGTON IN
47402-1329
US

V. Phone/Fax

Practice location:
  • Phone: 812-332-9217
  • Fax: 812-330-4474
Mailing address:
  • Phone: 812-353-2154
  • Fax: 812-353-5228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number01031189
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: