Provider Demographics
NPI:1093791030
Name:BLEW, STANLEY A (MD)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:A
Last Name:BLEW
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:PO BOX 1475
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-1475
Mailing Address - Country:US
Mailing Address - Phone:641-682-4594
Mailing Address - Fax:641-682-2123
Practice Address - Street 1:1005 PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:OTTUMWA
Practice Address - State:IA
Practice Address - Zip Code:52501-6408
Practice Address - Country:US
Practice Address - Phone:641-682-4594
Practice Address - Fax:641-682-2123
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA21477207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA110144452OtherRR MEDICARE
IA0020743Medicaid
IA0215376Medicaid
IA1020743Medicaid
IA1093791030Medicaid
IA1020743Medicaid
IA0020743Medicaid