Healthcare Provider Details

I. General information

NPI: 1245209501
Provider Name (Legal Business Name): KENNETH C. STEWART D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 04/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 JACKSON ST SW
GRAVETTE AR
72736-9121
US

IV. Provider business mailing address

1101 JACKSON ST SW SUITE B
GRAVETTE AR
72736-9121
US

V. Phone/Fax

Practice location:
  • Phone: 479-787-5291
  • Fax:
Mailing address:
  • Phone: 479-787-5291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2006005756
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: