Provider Demographics
NPI:1750515565
Name:STEWART, CAMPBELL L (MD)
Entity type:Individual
Prefix:DR
First Name:CAMPBELL
Middle Name:L
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 1:21 SOUTH ROAD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032
Mailing Address - Country:US
Mailing Address - Phone:860-679-4600
Mailing Address - Fax:860-679-3207
Practice Address - Street 1:21 SOUTH ROAD
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032
Practice Address - Country:US
Practice Address - Phone:860-679-4600
Practice Address - Fax:860-679-3207
Is Sole Proprietor?:No
Enumeration Date:2009-05-07
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT061363207ND0900X
WAMD60454651207N00000X, 207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMD60454651OtherLICENSE
WA50D0966896OtherCLIA
WAFS4379702OtherDEA
WA50D0966896OtherCLIA