Healthcare Provider Details

I. General information

NPI: 1457697088
Provider Name (Legal Business Name): THOMAS STEWART
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/31/2012
Last Update Date: 01/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 ALPINE BLVD
ALPINE CA
91901-2113
US

IV. Provider business mailing address

4718 JEWELL ST
SAN DIEGO CA
92109-3148
US

V. Phone/Fax

Practice location:
  • Phone: 619-445-2644
  • Fax:
Mailing address:
  • Phone: 619-787-9530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: