Provider Demographics
NPI:1164691028
Name:STEWART, LAURA EVELYN (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:EVELYN
Last Name:STEWART
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2175 HIGHWAY 75
Mailing Address - Street 2:STE 4
Mailing Address - City:BLOUNTVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37617-5861
Mailing Address - Country:US
Mailing Address - Phone:423-323-5290
Mailing Address - Fax:423-323-5653
Practice Address - Street 1:130 W RAVINE RD
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3837
Practice Address - Country:US
Practice Address - Phone:423-224-6711
Practice Address - Fax:423-224-6717
Is Sole Proprietor?:No
Enumeration Date:2008-02-25
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN41946207ZC0500X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA060881OtherGE MEDICAL LICENSE
GA491438200AMedicaid
GA52245654001OtherBLUE CROSS
GA581763128001OtherTRICARE
GA511I220072Medicare PIN