Healthcare Provider Details

I. General information

NPI: 1649320052
Provider Name (Legal Business Name): GLENN RUTLEDGE STEWART M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 W BAYOU PKWY
LAFAYETTE LA
70503-3605
US

IV. Provider business mailing address

607 W BAYOU PKWY
LAFAYETTE LA
70503-3605
US

V. Phone/Fax

Practice location:
  • Phone: 337-501-6466
  • Fax: 928-396-6431
Mailing address:
  • Phone: 337-501-6466
  • Fax: 928-396-6431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0203X
TaxonomyTherapeutic Radiology Physician
License Number2459
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: