Healthcare Provider Details

I. General information

NPI: 1306275359
Provider Name (Legal Business Name): REGINALD STEWART
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2013
Last Update Date: 11/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1812 SHARON AVE
INDIANAPOLIS IN
46222-2753
US

IV. Provider business mailing address

1812 SHARON AVE
INDIANAPOLIS IN
46222-2753
US

V. Phone/Fax

Practice location:
  • Phone: 317-339-4040
  • Fax:
Mailing address:
  • Phone: 317-339-4040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number8905106981
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number266127
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: