Healthcare Provider Details

I. General information

NPI: 1114085941
Provider Name (Legal Business Name): ANDRE ST. CLAIR STUART M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 UPPER RIVERDALE RD SE SUITE 100 A
RIVERDALE GA
30274-2635
US

IV. Provider business mailing address

5559 MOUNTAIN VIEW PASS
STONE MOUNTAIN GA
30087-6020
US

V. Phone/Fax

Practice location:
  • Phone: 770-907-7222
  • Fax: 770-991-3154
Mailing address:
  • Phone: 770-413-2663
  • Fax: 770-413-0638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number037707
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: