Provider Demographics
NPI:1205253408
Name:STEWART, DANE HADEN (MD)
Entity type:Individual
Prefix:
First Name:DANE
Middle Name:HADEN
Last Name:STEWART
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 1:1800 E PAVILION PL UNIT B
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-5499
Mailing Address - Country:US
Mailing Address - Phone:970-249-1210
Mailing Address - Fax:970-249-3057
Practice Address - Street 1:1800 E PAVILION PL UNIT B
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401
Practice Address - Country:US
Practice Address - Phone:970-249-1210
Practice Address - Fax:970-249-3057
Is Sole Proprietor?:No
Enumeration Date:2014-03-25
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT207872207W00000X
CODR.0059786207W00000X
AZR74549207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1205253408Medicaid