Provider Demographics
NPI:1740257914
Name:NEWSWANGER, BRUCE (DO)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:NEWSWANGER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 419569
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-9569
Mailing Address - Country:US
Mailing Address - Phone:781-280-1699
Mailing Address - Fax:781-276-6454
Practice Address - Street 1:600 EAST BLVD
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2483
Practice Address - Country:US
Practice Address - Phone:574-523-3160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001536207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200331530Medicaid
IN930017086OtherRAIL ROAD MEDICARE
IN000000082207OtherANTHEM
MI113067774Medicaid
ING54164Medicare UPIN
IN200331530Medicaid