Provider Demographics
NPI:1639352024
Name:JOHN R. SWENSON DPM, PC
Entity Type:Organization
Organization Name:JOHN R. SWENSON DPM, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:SWENSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:719-473-6677
Mailing Address - Street 1:2287 ROCKING HORSE CT
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80921-6401
Mailing Address - Country:US
Mailing Address - Phone:719-473-6677
Mailing Address - Fax:719-473-9219
Practice Address - Street 1:2287 ROCKING HORSE CT
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80921-6401
Practice Address - Country:US
Practice Address - Phone:719-473-6677
Practice Address - Fax:719-473-9219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-09
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO474213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01004746Medicaid
CO01004746Medicaid
COC50453Medicare PIN