Provider Demographics
NPI:1497791784
Name:STEWART, JIMMY LEE JR (MD)
Entity Type:Individual
Prefix:MR
First Name:JIMMY
Middle Name:LEE
Last Name:STEWART
Suffix:JR
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 1:2500 NORTH STATE STREET
Mailing Address - Street 2:HYPERTENSION
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-6850
Mailing Address - Fax:601-984-6853
Practice Address - Street 1:2500 NORTH STATE STREET
Practice Address - Street 2:DEPT OF MEDICINE DIVISION OF HYPERTENSION
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-6850
Practice Address - Fax:601-984-6853
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16401207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1133515Medicaid
MS00121927Medicaid
MSP00393117OtherRR MEDICARE - GROUP CN0867
MSP01201507Medicare PIN
MS302I117082Medicare PIN
MSP00393117OtherRR MEDICARE - GROUP CN0867
MSP00620207Medicare PIN
MS00121927Medicaid