Provider Demographics
NPI:1255459558
Name:SWANSON, JOHN DAVID IV (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVID
Last Name:SWANSON
Suffix:IV
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:1593 E POLSTON AVE
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-5326
Mailing Address - Country:US
Mailing Address - Phone:208-262-2300
Mailing Address - Fax:208-262-2390
Practice Address - Street 1:750 N SYRINGA ST STE 100
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-5275
Practice Address - Country:US
Practice Address - Phone:208-262-2600
Practice Address - Fax:208-262-2700
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2024-08-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IDM-90752083A0100X, 2083X0100X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1255459558Medicaid
ID1255459558Medicaid