Basic Information
| Provider Information | |||||||||
| NPI: | 1043285463 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DISMUKE | ||||||||
| FirstName: | STEWART | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD, MPH | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | DISMUKE | ||||||||
| OtherFirstName: | S. EDWARDS | ||||||||
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| OtherCredential: | MD, MPH | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1010 N KANSAS ST | ||||||||
| Address2: | SUITE #3049 | ||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672143124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162932620 | ||||||||
| FaxNumber: | 3162931882 | ||||||||
| Practice Location | |||||||||
| Address1: | 2707 E 21ST ST N | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672142249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166910249 | ||||||||
| FaxNumber: | 3166919939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2006 | ||||||||
| LastUpdateDate: | 03/08/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 04-23530 | KS | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 2083P0901X | 04-23530 | KS | N | Allopathic & Osteopathic Physicians | Preventive Medicine | Public Health & General Preventive Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1043285463 | 05 | KS | MEDICAID |