Provider Demographics
NPI:1902849417
Name:STEWART, MACK D (MD)
Entity Type:Individual
Prefix:
First Name:MACK
Middle Name:D
Last Name:STEWART
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 1:107 ROBERT E LEE DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-4602
Mailing Address - Country:US
Mailing Address - Phone:903-561-0300
Mailing Address - Fax:
Practice Address - Street 1:107 ROBERT E LEE DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-4602
Practice Address - Country:US
Practice Address - Phone:903-561-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8441207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX137131212Medicaid
TX0077EJOtherBCBS
TX137131207Medicaid
TX137131211Medicaid
TXTIN PLUS 044OtherTRICARE WINNSBORO LOCATION
TXTIN PLUS 005OtherTRICARE JV LOCATION
TXTIN PLUS 015OtherTRICARE TYLER LOCATION
TX137131212Medicaid
TX0077EJOtherBCBS
TX137131211Medicaid
TX8L0971Medicare Oscar/Certification
TX930089203Medicare PIN
TXC22287Medicare UPIN