Provider Demographics
NPI:1447225123
Name:KANIS, STEWART JOHN (DO)
Entity Type:Individual
Prefix:
First Name:STEWART
Middle Name:JOHN
Last Name:KANIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 N QUINCY AVE
Mailing Address - Street 2:
Mailing Address - City:OTTUMWA
Mailing Address - State:IA
Mailing Address - Zip Code:52501-3866
Mailing Address - Country:US
Mailing Address - Phone:641-455-5200
Mailing Address - Fax:641-455-5150
Practice Address - Street 1:920 N QUINCY AVE
Practice Address - Street 2:
Practice Address - City:OTTUMWA
Practice Address - State:IA
Practice Address - Zip Code:52501-3866
Practice Address - Country:US
Practice Address - Phone:641-455-5200
Practice Address - Fax:641-455-5150
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01944207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA110134681OtherRAILROAD MEDICARE
IA2193789Medicaid
IA3193789Medicaid
IA56107Medicare ID - Type UnspecifiedMEDICARE NUMBER
IA2193789Medicaid
IA56107Medicare PIN