Provider Demographics
NPI:1497775720
Name:STEWART, EDYTHE WOODRUFF (MD)
Entity Type:Individual
Prefix:MRS
First Name:EDYTHE
Middle Name:WOODRUFF
Last Name:STEWART
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:EDYTHE
Other - Middle Name:ETHELYNN
Other - Last Name:WOODRUFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:105 W EL PORTAL DR STE B
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95348-2858
Mailing Address - Country:US
Mailing Address - Phone:209-325-4897
Mailing Address - Fax:
Practice Address - Street 1:105 W EL PORTAL DR STE B
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95348-2858
Practice Address - Country:US
Practice Address - Phone:209-325-4897
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA65931208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A659310Medicaid
CA00A659310Medicaid
H55454Medicare UPIN