Provider Demographics
NPI:1386612315
Name:STEWART, JOHN R (OD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:STEWART
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 MEDFORD DR
Mailing Address - Street 2:
Mailing Address - City:GREER
Mailing Address - State:SC
Mailing Address - Zip Code:29650
Mailing Address - Country:US
Mailing Address - Phone:864-848-4808
Mailing Address - Fax:864-848-4980
Practice Address - Street 1:14055 E WADE HAMPTON BLVD
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29651-1500
Practice Address - Country:US
Practice Address - Phone:864-848-4808
Practice Address - Fax:864-848-4980
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2011-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1099152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC9614Medicare UPIN
SCU605330281Medicare ID - Type Unspecified