Provider Demographics
NPI:1518923283
Name:EWALT, JOHN E (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:E
Last Name:EWALT
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 1:4410 REGENT ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-4901
Mailing Address - Country:US
Mailing Address - Phone:608-233-9746
Mailing Address - Fax:
Practice Address - Street 1:4410 REGENT ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-4901
Practice Address - Country:US
Practice Address - Phone:608-233-9746
Practice Address - Fax:608-233-0026
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI24908-020207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30461000Medicaid
WI30461000Medicaid
WIB52681Medicare UPIN