Provider Demographics
NPI:1265460869
Name:MARTHA E STEWART MD LLC
Entity Type:Organization
Organization Name:MARTHA E STEWART MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:E
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-727-7701
Mailing Address - Street 1:4060 LONESOME RD
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70448-7085
Mailing Address - Country:US
Mailing Address - Phone:985-727-7701
Mailing Address - Fax:985-727-7375
Practice Address - Street 1:4060 LONESOME RD
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70448-7085
Practice Address - Country:US
Practice Address - Phone:985-727-7701
Practice Address - Fax:985-727-7375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-30
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CM04Medicare ID - Type Unspecified