Provider Demographics
NPI:1114907029
Name:STUART, REGINA K (MD)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:K
Last Name:STUART
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2518 E DUPONT RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1675
Mailing Address - Country:US
Mailing Address - Phone:260-432-4400
Mailing Address - Fax:260-969-6833
Practice Address - Street 1:5 FOUNDERS ST STE 102
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-2050
Practice Address - Country:US
Practice Address - Phone:609-456-2898
Practice Address - Fax:609-456-3078
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT57003208600000X
IN01061211A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200503510Medicaid
IN259990017Medicare PIN
IN233390CMedicare PIN
P00284311OtherRAILROAD MEDICARE
IN150640VVVMedicare PIN
203267938OtherINDIANA HEALTH NETWORK
INE93824Medicare UPIN
IN200503510AMedicaid
IN233390CMedicare PIN
18578OtherPHYSICIANS HEALTH PLAN
INP00284311Medicare PIN