Healthcare Provider Details

I. General information

NPI: 1588014807
Provider Name (Legal Business Name): DAVE STEWART M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2016
Last Update Date: 07/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 COLLEGE ST
BLAKELY GA
39823
US

IV. Provider business mailing address

360 COLLEGE ST
BLAKELY GA
39823-2554
US

V. Phone/Fax

Practice location:
  • Phone: 229-723-2660
  • Fax: 229-723-2663
Mailing address:
  • Phone: 229-723-2660
  • Fax: 229-723-2663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number81961
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: