Provider Demographics
NPI:1982118873
Name:STEWARD, JEFFERY DEREK
Entity type:Individual
Prefix:
First Name:JEFFERY
Middle Name:DEREK
Last Name:STEWARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2325 HOOVER AVE
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-7294
Mailing Address - Country:US
Mailing Address - Phone:614-626-3111
Mailing Address - Fax:
Practice Address - Street 1:2325 HOOVER AVE
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-7294
Practice Address - Country:US
Practice Address - Phone:614-626-3111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-30
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist