Basic Information
Provider Information | |||||||||
NPI: | 1861473647 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STEWART | ||||||||
FirstName: | THOMAS | ||||||||
MiddleName: | D | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 25 KINGSBRIDGE WAY | ||||||||
Address2: | CLINIC BUILDING, ROOM 2039 | ||||||||
City: | MADISON | ||||||||
State: | CT | ||||||||
PostalCode: | 064433407 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2034308949 | ||||||||
FaxNumber: | 2037372221 | ||||||||
Practice Location | |||||||||
Address1: | 20 YORK ST | ||||||||
Address2: | CLINIC BUILDING, ROOM 2039 | ||||||||
City: | NEW HAVEN | ||||||||
State: | CT | ||||||||
PostalCode: | 065103220 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2036882619 | ||||||||
FaxNumber: | 2037372221 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/09/2005 | ||||||||
LastUpdateDate: | 04/27/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 030776 | CT | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
ID | Type | State | Issuer | Description | 001307760 | 05 | CT |   | MEDICAID |