1770719486 NPI number — DR. KNOTRESHA FLORETH STEWART M.D.

Table of content: DR. KNOTRESHA FLORETH STEWART M.D. (NPI 1770719486)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770719486 NPI number — DR. KNOTRESHA FLORETH STEWART M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STEWART
Provider First Name:
KNOTRESHA
Provider Middle Name:
FLORETH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
OSEMOBOR
Provider Other First Name:
EHIKIOYA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1770719486
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/30/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
28 TOWN CENTER DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DUBLIN
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24084
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-835-0500
Provider Business Mailing Address Fax Number:
540-307-5070

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
28 TOWN CENTER DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DUBLIN
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24084
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-835-0500
Provider Business Practice Location Address Fax Number:
540-307-5070
Provider Enumeration Date:
06/09/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  0101245821 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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