Healthcare Provider Details

I. General information

NPI: 1316912868
Provider Name (Legal Business Name): RYAN CRAIG STUART O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/20/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 E IOWA ST
HOLBROOK AZ
86025-2770
US

IV. Provider business mailing address

PO BOX 760
HOLBROOK AZ
86025-0760
US

V. Phone/Fax

Practice location:
  • Phone: 928-524-6171
  • Fax: 928-524-3963
Mailing address:
  • Phone: 928-524-6171
  • Fax: 928-524-3963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1414
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: