Provider Demographics
NPI:1710242854
Name:SWANSON, BROCK A (DPM)
Entity type:Individual
Prefix:DR
First Name:BROCK
Middle Name:A
Last Name:SWANSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:752 N HIGH POINT RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53717-2236
Mailing Address - Country:US
Mailing Address - Phone:608-824-4000
Mailing Address - Fax:608-824-2674
Practice Address - Street 1:752 N HIGH POINT RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53717-2236
Practice Address - Country:US
Practice Address - Phone:608-824-4000
Practice Address - Fax:608-824-2674
Is Sole Proprietor?:No
Enumeration Date:2012-07-04
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1147-25213E00000X
PASC006387213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1710242854Medicaid