Provider Demographics
NPI:1962509620
Name:STEWART, TONYA CANNON (OD)
Entity Type:Individual
Prefix:DR
First Name:TONYA
Middle Name:CANNON
Last Name:STEWART
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 W. LAKEVIEW DRIVE
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-5221
Mailing Address - Country:US
Mailing Address - Phone:601-925-2020
Mailing Address - Fax:601-925-2010
Practice Address - Street 1:45 LAKEVIEW DR
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-5221
Practice Address - Country:US
Practice Address - Phone:601-925-2020
Practice Address - Fax:601-925-2010
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS640152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00880126Medicaid
MS00880126Medicaid
MSU74313Medicare UPIN
MS410000282Medicare ID - Type Unspecified