Provider Demographics
NPI:1609952332
Name:STAFFORD, ANDY J (MD)
Entity Type:Individual
Prefix:
First Name:ANDY
Middle Name:J
Last Name:STAFFORD
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 1329
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47402-1329
Mailing Address - Country:US
Mailing Address - Phone:812-353-2154
Mailing Address - Fax:812-353-5228
Practice Address - Street 1:2920 MCINTYRE DR
Practice Address - Street 2:SUITE 250
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-4221
Practice Address - Country:US
Practice Address - Phone:812-332-9217
Practice Address - Fax:812-330-4474
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01031189207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100207000AMedicaid
IN100207000AMedicaid
IN182840MMedicare ID - Type Unspecified
IN548980CMedicare ID - Type Unspecified