Provider Demographics
NPI:1437201407
Name:GRIZZARD, STEWART V (MD)
Entity type:Individual
Prefix:
First Name:STEWART
Middle Name:V
Last Name:GRIZZARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 WATSON BLVD
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31093-3431
Mailing Address - Country:US
Mailing Address - Phone:478-975-6880
Mailing Address - Fax:478-975-6869
Practice Address - Street 1:1112 PLAZA AVE STE B
Practice Address - Street 2:
Practice Address - City:EASTMAN
Practice Address - State:GA
Practice Address - Zip Code:31023-9012
Practice Address - Country:US
Practice Address - Phone:478-374-7801
Practice Address - Fax:478-374-7878
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043948207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000771966OMedicaid
GAG60855Medicare UPIN
GA000771966OMedicaid