Provider Demographics
NPI:1508809013
Name:JENNINGS, STEWART W (MD)
Entity Type:Individual
Prefix:
First Name:STEWART
Middle Name:W
Last Name:JENNINGS
Suffix:
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:PO BOX 91734
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23291-1734
Mailing Address - Country:US
Mailing Address - Phone:804-358-6100
Mailing Address - Fax:804-342-7619
Practice Address - Street 1:6433 CENTRALIA RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23832
Practice Address - Country:US
Practice Address - Phone:804-425-3627
Practice Address - Fax:804-425-7679
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101230656207R00000X
IN01072760A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1508809013Medicaid
IN201182770Medicaid
VA015496R53Medicare PIN
IN201182770Medicaid