Provider Demographics
NPI:1518301605
Name:STEWART, MICHAEL CHARLES JR (IDC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:CHARLES
Last Name:STEWART
Suffix:JR
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 TROUT AVENUE
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06349
Mailing Address - Country:US
Mailing Address - Phone:224-623-3289
Mailing Address - Fax:
Practice Address - Street 1:159 TROUT AVENUE
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06349
Practice Address - Country:US
Practice Address - Phone:224-623-3289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-19
Last Update Date:2013-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT3933OtherMILITARY-INDEPENDENT DUTY CORPSMAN