Provider Demographics
NPI:1700881679
Name:STEWART, RUSSELL L (DO)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:L
Last Name:STEWART
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:HC 61 BOX 56C
Mailing Address - Street 2:
Mailing Address - City:FRAMETOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26623-9401
Mailing Address - Country:US
Mailing Address - Phone:304-364-4136
Mailing Address - Fax:
Practice Address - Street 1:406 MAIN ST
Practice Address - Street 2:
Practice Address - City:SUTTON
Practice Address - State:WV
Practice Address - Zip Code:26601-1323
Practice Address - Country:US
Practice Address - Phone:304-765-2826
Practice Address - Fax:304-765-2841
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV733207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0049686000Medicaid
E05916Medicare UPIN
WV0049686000Medicaid
ST9261031Medicare ID - Type UnspecifiedGROUP MEDICARE I.D.