Provider Demographics
NPI:1770559551
Name:STONE, DWAIN LEE (MD)
Entity type:Individual
Prefix:DR
First Name:DWAIN
Middle Name:LEE
Last Name:STONE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:KEOKUK
Mailing Address - State:IA
Mailing Address - Zip Code:52632-2103
Mailing Address - Country:US
Mailing Address - Phone:507-269-0879
Mailing Address - Fax:
Practice Address - Street 1:11 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:KEOKUK
Practice Address - State:IA
Practice Address - Zip Code:52632-2103
Practice Address - Country:US
Practice Address - Phone:507-269-0879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA21682208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1770559551Medicaid
IA1770559551Medicaid