Provider Demographics
NPI:1235198227
Name:PFAFF, DANA STUART (MD)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:STUART
Last Name:PFAFF
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 775383
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-5383
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2475 NORTH PARK STE 10
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47203-2215
Practice Address - Country:US
Practice Address - Phone:812-376-9261
Practice Address - Fax:812-378-9518
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01029357A208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000537534OtherANTHEM PROVIDER NUMBER
IN100144870Medicaid
IN11485705OtherCAQH NUMBER
IN11485705OtherCAQH NUMBER
IN100144870Medicaid