Provider Demographics
NPI:1063496131
Name:SWENSON, ELDON J (MD)
Entity Type:Individual
Prefix:DR
First Name:ELDON
Middle Name:J
Last Name:SWENSON
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 1:620 S 76TH ST
Mailing Address - Street 2:SUITE 240
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53214-1599
Mailing Address - Country:US
Mailing Address - Phone:414-988-6350
Mailing Address - Fax:
Practice Address - Street 1:620 S 76TH ST
Practice Address - Street 2:SUITE 240
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53214-1599
Practice Address - Country:US
Practice Address - Phone:414-988-6350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20106-20208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI310013700Medicaid
WI0000-68088Medicare ID - Type UnspecifiedPROVIDER NUMBER
WI0013-73510Medicare ID - Type UnspecifiedPROVIDER NUMBER
WI310013700Medicaid
WI000-02002Medicare ID - Type UnspecifiedPROVIDER NUMBER
WI0001-01116Medicare ID - Type UnspecifiedPROVIDER NUMBER