Provider Demographics
NPI:1487617924
Name:SHULL, STEWART (MD)
Entity type:Individual
Prefix:
First Name:STEWART
Middle Name:
Last Name:SHULL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 E HALLANDALE BEACH BLVD
Mailing Address - Street 2:300A
Mailing Address - City:HALLANDALE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33009-4834
Mailing Address - Country:US
Mailing Address - Phone:954-458-7766
Mailing Address - Fax:954-457-8624
Practice Address - Street 1:2500 E HALLANDALE BEACH BLVD
Practice Address - Street 2:300A
Practice Address - City:HALLANDALE BEACH
Practice Address - State:FL
Practice Address - Zip Code:33009-4834
Practice Address - Country:US
Practice Address - Phone:954-458-7766
Practice Address - Fax:954-457-8624
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-07
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME0025473207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL056968200Medicaid
FLD60379Medicare UPIN
FL056968200Medicaid