Healthcare Provider Details

I. General information

NPI: 1730157439
Provider Name (Legal Business Name): JOHNNY CREED STEWART MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 04/08/2026
Certification Date: 04/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2829 S JACKSON AVE
JOPLIN MO
64804-2525
US

IV. Provider business mailing address

2829 S JACKSON AVE
JOPLIN MO
64804-2525
US

V. Phone/Fax

Practice location:
  • Phone: 417-624-0440
  • Fax:
Mailing address:
  • Phone: 417-624-0440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2026013576
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: