Provider Demographics
NPI:1225147804
Name:STUART, LEE O (MD)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:O
Last Name:STUART
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 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4294 LAUREL DR
Practice Address - Street 2:
Practice Address - City:LAKE ODESSA
Practice Address - State:MI
Practice Address - Zip Code:48849-8430
Practice Address - Country:US
Practice Address - Phone:616-374-7660
Practice Address - Fax:616-374-0270
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301037582208D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIB44057Medicare UPIN
MI1095027Medicaid
MI0345548OtherBLUE CROSS BLUE SHIELD MI
MI0345548Medicare ID - Type Unspecified
MILS037582OtherSTATE LICENSE MI