Healthcare Provider Details

I. General information

NPI: 1811958150
Provider Name (Legal Business Name): KENNETH STEWART MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 OLD PECOS TRL STE E
SANTA FE NM
87505-4777
US

IV. Provider business mailing address

1640 OLD PECOS TRL STE E
SANTA FE NM
87505-4777
US

V. Phone/Fax

Practice location:
  • Phone: 505-670-9778
  • Fax:
Mailing address:
  • Phone: 505-670-9778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number91-318
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number91-318
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number91-318
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: