Provider Demographics
NPI:1750319448
Name:SYVERUD, JAMES CARTER (MD)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:CARTER
Last Name:SYVERUD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:21 PARK PL
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-8872
Mailing Address - Country:US
Mailing Address - Phone:920-739-4361
Mailing Address - Fax:920-739-6368
Practice Address - Street 1:21 PARK PL
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-8872
Practice Address - Country:US
Practice Address - Phone:920-739-4361
Practice Address - Fax:920-739-6368
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI17340207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30246800Medicaid
WI30246800Medicaid
WIB54027Medicare UPIN