Provider Demographics
NPI:1164538690
Name:BUADOO-CROFFIE, JOSEPH M (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:M
Last Name:BUADOO-CROFFIE
Suffix:
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:PO BOX 1026
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1026
Mailing Address - Country:US
Mailing Address - Phone:317-777-6435
Mailing Address - Fax:317-777-6644
Practice Address - Street 1:705 RILEY HOSPITAL DR
Practice Address - Street 2:ROC 4210
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5109
Practice Address - Country:US
Practice Address - Phone:317-944-3774
Practice Address - Fax:317-944-8521
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010390232080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100387250Medicaid
KY64879851Medicaid
000000321534OtherANTHEM-DEAC-350593390
350593390-042OtherTRICARE-DEAC-350593390
KY64879851Medicaid
IN100387250Medicaid
145590AAAAMedicare ID - Type UnspecifiedUPA-237328642