Healthcare Provider Details

I. General information

NPI: 1902809460
Provider Name (Legal Business Name): STEWART EDWARD TEAL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 09/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 GRAND AVE STE D
SACRAMENTO CA
95838-3466
US

IV. Provider business mailing address

811 GRAND AVE STE D
SACRAMENTO CA
95838-3466
US

V. Phone/Fax

Practice location:
  • Phone: 916-922-9868
  • Fax: 916-922-7342
Mailing address:
  • Phone: 916-922-9868
  • Fax: 916-922-7342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberC30919
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: