Provider Demographics
NPI:1225114051
Name:STEWART, MARK JAY (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JAY
Last Name:STEWART
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 1:3390 PEACHTREE RD NE STE 1500
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30326-2822
Mailing Address - Country:US
Mailing Address - Phone:404-920-4950
Mailing Address - Fax:
Practice Address - Street 1:2100 CENTRAL AVE STE 6
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-6709
Practice Address - Country:US
Practice Address - Phone:770-929-9033
Practice Address - Fax:706-722-7454
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA032058207L00000X, 207LP2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000413696EMedicaid
GA000413696EMedicaid
GAE73186Medicare UPIN