Provider Demographics
NPI:1750378675
Name:STEWART, LARRY PAUL (MD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:PAUL
Last Name:STEWART
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:L
Other - Middle Name:PAUL
Other - Last Name:STEWART
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:8 BROADVIEW FARM RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8501
Mailing Address - Country:US
Mailing Address - Phone:314-576-4046
Mailing Address - Fax:314-576-4046
Practice Address - Street 1:1408 N KINGSHIGHWAY BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63113-1400
Practice Address - Country:US
Practice Address - Phone:314-361-8283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-05
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6898207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201367703Medicaid
A09908Medicare UPIN
MO201367703Medicaid