Provider Demographics
NPI:1750332557
Name:STEWART, DIANE MARIE (MD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:STEWART
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1607 SAINT JAMES CT
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-5352
Mailing Address - Country:US
Mailing Address - Phone:850-521-5700
Mailing Address - Fax:850-521-5701
Practice Address - Street 1:1615 MAHAN CENTER BLVD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5443
Practice Address - Country:US
Practice Address - Phone:850-521-5753
Practice Address - Fax:850-521-5701
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0516032084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA051603OtherSTATE LICENSE
GA051603OtherSTATE LICENSE