Provider Demographics
NPI:1376531004
Name:SWENSON, JEFFREY SCOTT (MD)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:SCOTT
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 1:1224 8TH STREET
Mailing Address - Street 2:
Mailing Address - City:RUPERT
Mailing Address - State:ID
Mailing Address - Zip Code:83350-1532
Mailing Address - Country:US
Mailing Address - Phone:208-434-8236
Mailing Address - Fax:208-436-1312
Practice Address - Street 1:1308 8TH ST STE 1
Practice Address - Street 2:
Practice Address - City:RUPERT
Practice Address - State:ID
Practice Address - Zip Code:83350
Practice Address - Country:US
Practice Address - Phone:208-436-4322
Practice Address - Fax:208-436-1312
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-06
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM9766207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDM0027582Medicaid
ID78193OtherBLX
IDM8073867Medicaid
ID78193OtherBLX
IDM0027582Medicaid