Provider Demographics
NPI:1912957655
Name:STEWART, TERESA C (MD)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:C
Last Name:STEWART
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 KENT RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-1698
Mailing Address - Country:US
Mailing Address - Phone:229-353-7337
Mailing Address - Fax:
Practice Address - Street 1:39 KENT RD
Practice Address - Street 2:SUITE 5
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-1698
Practice Address - Country:US
Practice Address - Phone:229-353-7337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA57022208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA492868212AMedicaid
GA492868212AMedicaid
GA37BBHBTMedicare ID - Type Unspecified