Provider Demographics
NPI:1467539429
Name:ROGER H STEWART MD PA
Entity Type:Organization
Organization Name:ROGER H STEWART MD PA
Other - Org Name:DERMATOLOGIC LASER & SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:KARTIKIS
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-908-7534
Mailing Address - Street 1:6550 N FEDERAL HWY STE 320
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-1400
Mailing Address - Country:US
Mailing Address - Phone:954-491-0510
Mailing Address - Fax:954-491-0562
Practice Address - Street 1:6550 N FEDERAL HWY STE 320
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-1400
Practice Address - Country:US
Practice Address - Phone:954-491-0510
Practice Address - Fax:954-491-0562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0023885207N00000X
FLSU14600291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
K0561OtherMEDICARE PTAN
G80775Medicare UPIN