Provider Demographics
NPI:1770075178
Name:STEWART, DARRYL (FL LHA 3527290)
Entity type:Individual
Prefix:
First Name:DARRYL
Middle Name:
Last Name:STEWART
Suffix:
Gender:M
Credentials:FL LHA 3527290
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1608 SEQUOIA DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32301-2734
Mailing Address - Country:US
Mailing Address - Phone:850-878-8823
Mailing Address - Fax:
Practice Address - Street 1:1608 SEQUOIA DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-2734
Practice Address - Country:US
Practice Address - Phone:850-878-8823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLD044821171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3527290OtherNATIONAL PRODUCER NUMBER