Provider Demographics
NPI:1518209592
Name:SWANSON, RAYMOND ELMER (MD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:ELMER
Last Name:SWANSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:RAYMOND
Other - Middle Name:ELMER
Other - Last Name:SWANSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:207 ISLAND VIEW DR
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-5213
Mailing Address - Country:US
Mailing Address - Phone:574-533-0066
Mailing Address - Fax:
Practice Address - Street 1:207 ISLAND VIEW DR
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-5213
Practice Address - Country:US
Practice Address - Phone:574-533-0066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-18
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010304708291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory