Provider Demographics
NPI:1710007398
Name:ISAACSON, STUART L (DO)
Entity type:Individual
Prefix:
First Name:STUART
Middle Name:L
Last Name:ISAACSON
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 1:1400 WEST STATE STREET
Mailing Address - Street 2:BLDG B, SUITE C
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47907
Mailing Address - Country:US
Mailing Address - Phone:765-494-0111
Mailing Address - Fax:765-496-6656
Practice Address - Street 1:1400 W STATE ST STE C
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-3438
Practice Address - Country:US
Practice Address - Phone:765-494-0111
Practice Address - Fax:765-496-6656
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2017-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI463102083X0100X
IN02005007A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIWI1447011Medicare UPIN
WIWI1449Medicare PIN
WIWI1448011Medicare UPIN
WIWI1449011Medicare UPIN
WIWI1448Medicare PIN
WIWI1447Medicare PIN