Provider Demographics
NPI:1114150679
Name:WARDLAW, STEPHEN CLARK (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:CLARK
Last Name:WARDLAW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 HIGHROCK
Mailing Address - Street 2:
Mailing Address - City:LYME
Mailing Address - State:CT
Mailing Address - Zip Code:06371-3450
Mailing Address - Country:US
Mailing Address - Phone:860-434-3322
Mailing Address - Fax:
Practice Address - Street 1:1 HIGHROCK
Practice Address - Street 2:
Practice Address - City:LYME
Practice Address - State:CT
Practice Address - Zip Code:06371-3450
Practice Address - Country:US
Practice Address - Phone:860-434-3322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-01
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT139731744R1102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744R1102XOther Service ProvidersSpecialistResearch Study