Provider Demographics
NPI:1740744317
Name:SCHWANENBERG, KEVIN JON
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:JON
Last Name:SCHWANENBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1328 SAND VERBENA WAY
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76177-7211
Mailing Address - Country:US
Mailing Address - Phone:817-805-0300
Mailing Address - Fax:
Practice Address - Street 1:4375 BOOTH CALLOWAY RD STE 505
Practice Address - Street 2:
Practice Address - City:NORTH RICHLAND HILLS
Practice Address - State:TX
Practice Address - Zip Code:76180-8359
Practice Address - Country:US
Practice Address - Phone:817-805-0300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-28
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1031092085U0001X, 2471V0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471V0105XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistVascular Sonography
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound