Healthcare Provider Details

I. General information

NPI: 1710007398
Provider Name (Legal Business Name): STUART L. ISAACSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 06/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 W STATE ST STE C
WEST LAFAYETTE IN
47906-3438
US

IV. Provider business mailing address

1400 WEST STATE STREET BLDG B, SUITE C
WEST LAFAYETTE IN
47907
US

V. Phone/Fax

Practice location:
  • Phone: 765-494-0111
  • Fax: 765-496-6656
Mailing address:
  • Phone: 765-494-0111
  • Fax: 765-496-6656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number46310
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02005007A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: