Provider Demographics
NPI:1861448243
Name:SWANSON, PAUL MATHEW (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:MATHEW
Last Name:SWANSON
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 1:1871 SE TIFFANY AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7585
Mailing Address - Country:US
Mailing Address - Phone:772-335-5666
Mailing Address - Fax:772-335-4826
Practice Address - Street 1:1871 SE TIFFANY AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7585
Practice Address - Country:US
Practice Address - Phone:772-335-5666
Practice Address - Fax:772-335-4826
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0075493207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL900002186OtherRAILROAD MEDICARE
FL0075493OtherSTATE LICENSE NUMBER
FL43952OtherBLUE CROSS BLUE SHIELD
FL254047900Medicaid
FLF73315Medicare UPIN
FL0075493OtherSTATE LICENSE NUMBER