Provider Demographics
NPI:1477641181
Name:SWAN, ROBERT JOHN (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:JOHN
Last Name:SWAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:ROBERT
Other - Middle Name:JOHN
Other - Last Name:SWAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:600 MEDICAL DR
Mailing Address - Street 2:STE 214
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385
Mailing Address - Country:US
Mailing Address - Phone:636-332-3390
Mailing Address - Fax:636-327-4554
Practice Address - Street 1:600 MEDICAL DR
Practice Address - Street 2:STE 214
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385
Practice Address - Country:US
Practice Address - Phone:636-332-3390
Practice Address - Fax:636-327-4554
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO101350207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B56993Medicare UPIN
000094891Medicare ID - Type Unspecified