Provider Demographics
NPI:1922275163
Name:STEWART, HERBERT LEE
Entity Type:Individual
Prefix:
First Name:HERBERT
Middle Name:LEE
Last Name:STEWART
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10876 TARIN DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-4808
Mailing Address - Country:US
Mailing Address - Phone:904-757-1407
Mailing Address - Fax:904-757-1407
Practice Address - Street 1:10876 TARIN DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-4808
Practice Address - Country:US
Practice Address - Phone:904-757-1407
Practice Address - Fax:904-757-1407
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL680842596172A00000X, 347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No347C00000XTransportation ServicesPrivate Vehicle
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL680842596Medicaid