Provider Demographics
NPI:1396837852
Name:STEWART, EARL L (MD)
Entity Type:Individual
Prefix:
First Name:EARL
Middle Name:L
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 1:2815 N HIGHLAND AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-1729
Mailing Address - Country:US
Mailing Address - Phone:731-660-6055
Mailing Address - Fax:731-660-6039
Practice Address - Street 1:2815 N HIGHLAND AVE
Practice Address - Street 2:SUITE C
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-1729
Practice Address - Country:US
Practice Address - Phone:731-660-6055
Practice Address - Fax:731-660-6039
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN30977207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3832495Medicaid
TN3832495Medicaid
TN3832495Medicare ID - Type Unspecified