1285697318 NPI number — DOUGLAS GERALD SWANSON MD

Table of content: DOUGLAS GERALD SWANSON MD (NPI 1285697318)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285697318 NPI number — DOUGLAS GERALD SWANSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SWANSON
Provider First Name:
DOUGLAS
Provider Middle Name:
GERALD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SWANSON
Provider Other First Name:
DOUGLAS
Provider Other Middle Name:
GERALD
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD PC
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1285697318
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/28/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
455 E PIKES PEAK AVE
Provider Second Line Business Mailing Address:
STE 105
Provider Business Mailing Address City Name:
COLORADO SPRINGS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80903-3672
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-635-7288
Provider Business Mailing Address Fax Number:
719-473-6113

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
455 E PIKES PEAK AVE
Provider Second Line Business Practice Location Address:
STE 105
Provider Business Practice Location Address City Name:
COLORADO SPRINGS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80903-3672
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-635-7288
Provider Business Practice Location Address Fax Number:
719-473-6113
Provider Enumeration Date:
04/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  24789 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01247899 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: C530248 . This is a "MEDICARE ID-TYPE UNSPECIFIED" identifier . This identifiers is of the category "OTHER".




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