Provider Demographics
NPI:1629647805
Name:DEWAARD, JOHN (DO)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:DEWAARD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10310 THE GROVE BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70836-6455
Mailing Address - Country:US
Mailing Address - Phone:225-388-6630
Mailing Address - Fax:225-761-5702
Practice Address - Street 1:10310 THE GROVE BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70836-6455
Practice Address - Country:US
Practice Address - Phone:225-388-6630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-22
Last Update Date:2025-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA347471207QS0010X
MI5101028098207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE470553011-00Medicaid