Provider Demographics
NPI:1407875545
Name:SWANSON, KENT A (MD)
Entity Type:Individual
Prefix:
First Name:KENT
Middle Name:A
Last Name:SWANSON
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 1:3116 W MARCH LN
Mailing Address - Street 2:SUITE 200
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-2369
Mailing Address - Country:US
Mailing Address - Phone:209-473-6555
Mailing Address - Fax:209-473-6544
Practice Address - Street 1:1600 N ROSE AVE
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93030-3722
Practice Address - Country:US
Practice Address - Phone:805-988-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG58447207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G584470Medicaid
050083641OtherRAILROAD MEDICARE
CAGR0081300Medicaid
CAGR0081301Medicaid
CAGR0081302Medicaid
CAW14219AMedicare PIN
CAW14219BMedicare PIN
CAGR0081302Medicaid
CAW14219Medicare PIN
CAGR0081300Medicaid
CAGR0081301Medicaid
CAWG58447BMedicare PIN