Provider Demographics
NPI:1710923149
Name:STEWART, ANGELENE MARCELL (DO)
Entity Type:Individual
Prefix:
First Name:ANGELENE
Middle Name:MARCELL
Last Name:STEWART
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7120 MCCART AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76133-4200
Mailing Address - Country:US
Mailing Address - Phone:817-294-5624
Mailing Address - Fax:817-294-4711
Practice Address - Street 1:7120 MCCART AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76133-4200
Practice Address - Country:US
Practice Address - Phone:817-294-5624
Practice Address - Fax:817-294-4711
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1077207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F7340Medicare PIN