Provider Demographics
NPI:1659358901
Name:STEWART, EDWARD GRANVILLE (OD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:GRANVILLE
Last Name:STEWART
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 S GARFIELD AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-5501
Mailing Address - Country:US
Mailing Address - Phone:231-947-2020
Mailing Address - Fax:
Practice Address - Street 1:515 W 14TH ST
Practice Address - Street 2:SUITE D
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-4059
Practice Address - Country:US
Practice Address - Phone:231-947-2020
Practice Address - Fax:231-947-2002
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004160152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI944697888Medicaid
V03010Medicare UPIN
MI944697888Medicaid