Provider Demographics
NPI:1003117490
Name:STEWART, JOHNNY JAMORA (SUBMARINE-IDC)
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:JAMORA
Last Name:STEWART
Suffix:
Gender:M
Credentials:SUBMARINE-IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:USS LA JOLLA SSN 701
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96671
Mailing Address - Country:US
Mailing Address - Phone:808-590-0362
Mailing Address - Fax:
Practice Address - Street 1:USS LA JOLLA SSN 701
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96671-2381
Practice Address - Country:US
Practice Address - Phone:808-590-0362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-16
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman