Provider Demographics
NPI:1306275359
Name:STEWART, REGINALD
Entity type:Individual
Prefix:
First Name:REGINALD
Middle Name:
Last Name:STEWART
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1812 SHARON AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46222-2753
Mailing Address - Country:US
Mailing Address - Phone:317-339-4040
Mailing Address - Fax:
Practice Address - Street 1:1812 SHARON AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46222-2753
Practice Address - Country:US
Practice Address - Phone:317-339-4040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-08
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN8905106981172A00000X
IN266127172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver