Provider Demographics
NPI:1346237476
Name:SWOFFORD, MINATI D
Entity Type:Individual
Prefix:
First Name:MINATI
Middle Name:D
Last Name:SWOFFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MINA
Other - Middle Name:D
Other - Last Name:SWOFFORD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD PC
Mailing Address - Street 1:2101 JACKSON ST
Mailing Address - Street 2:STE 118
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46016-4386
Mailing Address - Country:US
Mailing Address - Phone:765-683-3160
Mailing Address - Fax:765-646-8367
Practice Address - Street 1:2101 JACKSON ST
Practice Address - Street 2:STE 118
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46016-4386
Practice Address - Country:US
Practice Address - Phone:765-683-3160
Practice Address - Fax:765-646-8367
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-04
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01042478A207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100475600Medicaid
IN132590FFMedicare PIN
IN100475600Medicaid
IN212630AMedicare PIN