Provider Demographics
NPI:1942278148
Name:STEWART, ERIC BLAINE (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:BLAINE
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:PO BOX 44008
Mailing Address - Street 2:UFJP PROVIDER ENROLLMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:761 EDGEWOOD AVE N
Practice Address - Street 2:UFJP COMMONWEALTH FAMILY PRACTICE CENTER
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32254-3013
Practice Address - Country:US
Practice Address - Phone:904-633-0500
Practice Address - Fax:904-633-0519
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME52949207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE22536Medicare UPIN
FL08551WMedicare PIN
FL08551ZMedicare PIN