Provider Demographics
NPI:1811924475
Name:STAUFFER, DWIGHT LEE (MD)
Entity type:Individual
Prefix:
First Name:DWIGHT
Middle Name:LEE
Last Name:STAUFFER
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 1:4883 E HERITAGE WOODS RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-9313
Mailing Address - Country:US
Mailing Address - Phone:812-320-0030
Mailing Address - Fax:
Practice Address - Street 1:2209 JOHN R WOODEN DR
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46151-1840
Practice Address - Country:US
Practice Address - Phone:765-352-9536
Practice Address - Fax:765-349-6433
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01025006207VG0400X, 207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200377200OtherMEDICAID GROUP
IN1003455410Medicaid
IN1104827633OtherGROUP NPI
IN163460003Medicare PIN
INB29178Medicare UPIN
IN191430KMedicare PIN