Provider Demographics
NPI:1114960614
Name:STEWART, JEREMY (MPT)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:
Last Name:STEWART
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2030 S PATRICK DR
Mailing Address - Street 2:STE 3
Mailing Address - City:INDIAN HARBOUR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32937-4400
Mailing Address - Country:US
Mailing Address - Phone:321-773-8155
Mailing Address - Fax:321-773-8154
Practice Address - Street 1:2030 S PATRICK DR
Practice Address - Street 2:STE 3
Practice Address - City:INDIAN HARBOUR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32937-4400
Practice Address - Country:US
Practice Address - Phone:321-773-8155
Practice Address - Fax:321-773-8154
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT19380225100000X
2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT-19380OtherSTATE OF FL. PT LICENSE NUMBER
FLK3234Medicare ID - Type UnspecifiedMEDICARE GROUP ID
FLY0658ZMedicare PIN