Provider Demographics
NPI:1942210406
Name:STEWART, CHARLES HERBERT (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:HERBERT
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 1:3650 N UNIVERSITY AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-6656
Mailing Address - Country:US
Mailing Address - Phone:801-375-4100
Mailing Address - Fax:801-427-3251
Practice Address - Street 1:3650 N UNIVERSITY AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-6656
Practice Address - Country:US
Practice Address - Phone:801-375-4100
Practice Address - Fax:801-427-3251
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT167503-1205208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery