Provider Demographics
NPI:1942278452
Name:STEWART, JACK O (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:O
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 1:1010 W LA VETA AVE STE 750
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4312
Mailing Address - Country:US
Mailing Address - Phone:714-361-6600
Mailing Address - Fax:714-919-8804
Practice Address - Street 1:1310 W STEWART DR STE 408
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3855
Practice Address - Country:US
Practice Address - Phone:714-639-9401
Practice Address - Fax:714-919-8807
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG48397207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1912919804OtherNPI - TYPE 2
CAWG48397DOtherPTAN
CA1912919804OtherMEDI-CAL
CACG5665OtherRAIL ROAD MEDICARE - GROUP PTAN
CA290003382OtherRAIL ROAD MEDICARE - PROVIDER PTAN
CAW1514OtherMEDICARE PTAN - TYPE 2
CAE02678Medicare UPIN
CAHW1514AOtherMEDICARE PTAN - TYPE 2
CAE02678Medicare UPIN