Basic Information
| Provider Information | |||||||||
| NPI: | 1609952332 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STAFFORD | ||||||||
| FirstName: | ANDY | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1329 | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474021329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123532154 | ||||||||
| FaxNumber: | 8123535228 | ||||||||
| Practice Location | |||||||||
| Address1: | 2920 MCINTYRE DR | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474034221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123329217 | ||||||||
| FaxNumber: | 8123304474 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 12/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 01031189 | IN | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 100207000A | 05 | IN | MEDICAID |