Basic Information
| Provider Information | |||||||||
| NPI: | 1316002504 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STEWART | ||||||||
| FirstName: | CONNIE | ||||||||
| MiddleName: | CHING-YUAN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3205 N ACADEMY BLVD | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809175147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196325700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 410 GOLD PASS HTS | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809063882 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196325700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2006 | ||||||||
| LastUpdateDate: | 04/05/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 62664741205 | UT | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | DR.0051854 | CO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 54870828 | 05 | CO | MEDICAID |