Provider Demographics
NPI:1609987510
Name:QUISLING, STEWART (MD)
Entity Type:Individual
Prefix:
First Name:STEWART
Middle Name:
Last Name:QUISLING
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 1:220 STANDIFORD AVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-1159
Mailing Address - Country:US
Mailing Address - Phone:209-579-5628
Mailing Address - Fax:209-579-5637
Practice Address - Street 1:3340 TULLY RD
Practice Address - Street 2:D-2
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-0838
Practice Address - Country:US
Practice Address - Phone:209-523-5195
Practice Address - Fax:209-523-5197
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC3230002084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA770388035OtherBLUE SHIELD
CAA34886Medicare UPIN
CA770388035OtherBLUE SHIELD