Provider Demographics
NPI:1407943053
Name:ODELL, STEWART I (MD)
Entity Type:Individual
Prefix:
First Name:STEWART
Middle Name:I
Last Name:ODELL
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 1:2310 DEAN ST
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60175
Mailing Address - Country:US
Mailing Address - Phone:630-584-8984
Mailing Address - Fax:630-584-1308
Practice Address - Street 1:2310 DEAN ST
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60175-1065
Practice Address - Country:US
Practice Address - Phone:630-584-8984
Practice Address - Fax:630-584-1308
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL312040Medicare ID - Type Unspecified
D10174Medicare UPIN