Provider Demographics
NPI:1669658480
Name:STEWART, DOUG HUGH (LDO)
Entity Type:Individual
Prefix:MR
First Name:DOUG
Middle Name:HUGH
Last Name:STEWART
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:MR
Other - First Name:DOUG
Other - Middle Name:HUGH
Other - Last Name:STEWART
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LDO
Mailing Address - Street 1:1550 RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-4161
Mailing Address - Country:US
Mailing Address - Phone:904-354-1021
Mailing Address - Fax:904-355-7840
Practice Address - Street 1:1550 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4161
Practice Address - Country:US
Practice Address - Phone:904-354-1021
Practice Address - Fax:904-355-7840
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-10
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO3413156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL06704100001OtherDME
FL06704100001OtherDME