Healthcare Provider Details

I. General information

NPI: 1518911676
Provider Name (Legal Business Name): MARIAN W STEWART D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 04/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10994 HISTORIC HIGHWAY 165 STE D
HOLLISTER MO
65672-5606
US

IV. Provider business mailing address

PO BOX 8781
SPRINGFIELD MO
65801-8781
US

V. Phone/Fax

Practice location:
  • Phone: 417-239-0079
  • Fax: 417-239-1228
Mailing address:
  • Phone: 417-339-5691
  • Fax: 417-339-7335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number101644
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: