Provider Demographics
NPI:1609890623
Name:SWEET, JOHN BOSTWICK (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:BOSTWICK
Last Name:SWEET
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 1:4625 CHURCHILL ST
Mailing Address - Street 2:SUITE 211
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-5868
Mailing Address - Country:US
Mailing Address - Phone:651-765-9800
Mailing Address - Fax:
Practice Address - Street 1:7455 VILLAGE DR
Practice Address - Street 2:
Practice Address - City:LINO LAKES
Practice Address - State:MN
Practice Address - Zip Code:55014-1181
Practice Address - Country:US
Practice Address - Phone:651-717-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN45874207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN37517500Medicaid
P00338588OtherMEDICARE RAILROAD
030000278Medicare PIN
P00338588OtherMEDICARE RAILROAD