Provider Demographics
NPI:1457495566
Name:STEWART, CHARLES R (RDCS, RVT)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:R
Last Name:STEWART
Suffix:
Gender:M
Credentials:RDCS, RVT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2411 STANWICK RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:MD
Mailing Address - Zip Code:21131-1519
Mailing Address - Country:US
Mailing Address - Phone:410-666-8526
Mailing Address - Fax:
Practice Address - Street 1:5530 WISCONSIN AVE
Practice Address - Street 2:SUITE 915
Practice Address - City:CHEVY CHASE
Practice Address - State:MD
Practice Address - Zip Code:20815-4404
Practice Address - Country:US
Practice Address - Phone:301-654-0591
Practice Address - Fax:301-654-0376
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD14718293D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FDCV02Medicare PIN