=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093731366
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JORDAN R. STEWART, DPM, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9622 DEERECO ROAD
-----------------------------------------------------
City | TIMONIUM
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21093
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-560-2777
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9622 DEERECO ROAD
-----------------------------------------------------
City | TIMONIUM
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21093
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-560-2777
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PODIATRIST/OWNER
-----------------------------------------------------
Name | DR. JORDAN RICHARD STEWART
-----------------------------------------------------
Credential | D.P.M.
-----------------------------------------------------
Telephone | 410-560-2777
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 01433
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------