Healthcare Provider Details

I. General information

NPI: 1285689778
Provider Name (Legal Business Name): LARRY D. STEWART JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 07/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1024 KEITH DR
PERRY GA
31069-2947
US

IV. Provider business mailing address

1024 KEITH DR
PERRY GA
31069-2947
US

V. Phone/Fax

Practice location:
  • Phone: 478-987-3445
  • Fax: 478-987-3102
Mailing address:
  • Phone: 478-987-3445
  • Fax: 478-987-3102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number027123
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: