Provider Demographics
NPI:1477668713
Name:STEWART, SALLY ROBERTSON (DO)
Entity Type:Individual
Prefix:DR
First Name:SALLY
Middle Name:ROBERTSON
Last Name:STEWART
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 61 BOX 56C
Mailing Address - Street 2:
Mailing Address - City:FRAMETOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26623-9401
Mailing Address - Country:US
Mailing Address - Phone:304-364-4136
Mailing Address - Fax:
Practice Address - Street 1:100 HOYLMAN DR
Practice Address - Street 2:
Practice Address - City:GASSAWAY
Practice Address - State:WV
Practice Address - Zip Code:26624-9321
Practice Address - Country:US
Practice Address - Phone:304-364-1093
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV734207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0049676000Medicaid
WVE05915Medicare UPIN
WVST0943591Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER