Provider Demographics
NPI:1649320052
Name:STEWART, GLENN RUTLEDGE (MD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:RUTLEDGE
Last Name:STEWART
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:607 W BAYOU PKWY
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-3605
Mailing Address - Country:US
Mailing Address - Phone:337-501-6466
Mailing Address - Fax:928-396-6431
Practice Address - Street 1:607 W BAYOU PKWY
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-3605
Practice Address - Country:US
Practice Address - Phone:337-501-6466
Practice Address - Fax:928-396-6431
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK24592085R0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKE42185Medicare UPIN
0000BKCCMMedicare ID - Type Unspecified