Healthcare Provider Details

I. General information

NPI: 1902998313
Provider Name (Legal Business Name): CARY STEWART MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2006
Last Update Date: 05/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 AVENIDA PICO SUITE C
SAN CLEMENTE CA
92673-6957
US

IV. Provider business mailing address

1001 AVENIDA PICO SUITE C
SAN CLEMENTE CA
92673-6957
US

V. Phone/Fax

Practice location:
  • Phone: 949-542-6154
  • Fax: 949-542-7154
Mailing address:
  • Phone: 949-542-6154
  • Fax: 949-542-7154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA69557
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License NumberA69557
License Number StateCA

VIII. Authorized Official

Name: CARY C STEWART
Title or Position: PRESIDENT
Credential: MD, PHD
Phone: 949-542-6154