Provider Demographics
NPI:1992702054
Name:SWEENEY, JOHN NOLAN (DO)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:NOLAN
Last Name:SWEENEY
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 1:1978 ROCKLEDGE BLVD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-3722
Mailing Address - Country:US
Mailing Address - Phone:321-631-0392
Mailing Address - Fax:
Practice Address - Street 1:1978 ROCKLEDGE BLVD
Practice Address - Street 2:STE 108
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-3722
Practice Address - Country:US
Practice Address - Phone:321-631-0392
Practice Address - Fax:321-631-5787
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-05
Last Update Date:2010-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS6941207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOS6941OtherME NUMBER
FL339875052OtherTRUST ID NUMBER
FL110243726OtherRAILROAD MEDICARE ID
FL1525272OtherUNITED MINE WORKERS ID
FL21149357906OtherBEECH STREET PROVIDER ID
FL57193OtherBCBS
FL339875052OtherTRUST ID NUMBER
FL57193OtherBCBS