Provider Demographics
NPI:1083658207
Name:STEWART, JEAN M (OD)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:M
Last Name:STEWART
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3501 SILVERSIDE ROAD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19810-4910
Mailing Address - Country:US
Mailing Address - Phone:302-479-3937
Mailing Address - Fax:302-477-2650
Practice Address - Street 1:3501 SILVERSIDE ROAD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19810-4910
Practice Address - Country:US
Practice Address - Phone:302-479-3937
Practice Address - Fax:302-477-2650
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE130001212152W00000X
DE13-0001212152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000038674Medicaid
U74436Medicare UPIN
DEU74436Medicare UPIN
DE019002057Medicare ID - Type Unspecified