Provider Demographics
NPI:1477572824
Name:SWANSON, JOHN DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DAVID
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 1:4395 GLIDDEN DR
Mailing Address - Street 2:
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235-9185
Mailing Address - Country:US
Mailing Address - Phone:920-450-4056
Mailing Address - Fax:
Practice Address - Street 1:323 S 18TH AVE
Practice Address - Street 2:
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235-1401
Practice Address - Country:US
Practice Address - Phone:920-450-4056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2013-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21867-020208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
B56998Medicare UPIN