Provider Demographics
NPI:1699758524
Name:STUY, JOHN WILLEM (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WILLEM
Last Name:STUY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2705 N LEBANON ST
Mailing Address - Street 2:SUITE 315
Mailing Address - City:LEBANON
Mailing Address - State:IN
Mailing Address - Zip Code:46052-8621
Mailing Address - Country:US
Mailing Address - Phone:765-485-8855
Mailing Address - Fax:765-485-8850
Practice Address - Street 1:2705 N LEBANON ST
Practice Address - Street 2:SUITE 315
Practice Address - City:LEBANON
Practice Address - State:IN
Practice Address - Zip Code:46052-8621
Practice Address - Country:US
Practice Address - Phone:765-485-8855
Practice Address - Fax:765-485-8850
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL01037305A207R00000X
IN01037305A207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100354540Medicaid
IN100354540Medicaid
IN220620IIMedicare ID - Type Unspecified