Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204E00000X | Oral & Maxillofacial Surgeon | DN0006161 | FL |
NPI | 1205877495 |
---|---|
Provider Name | Stanley Stewart |
First Address | Tamarac, FL 33321-2979 |
Second Address | Tamarac, FL 33321-2979 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/06/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
85239A | BLUE CROSS BLUE SHIELD (01) | FL |
S70701 | UNITED CONCORDIA (01) | FL |
T85683 | (02) | FL |