Healthcare Provider Details

I. General information

NPI: 1629647805
Provider Name (Legal Business Name): JOHN DEWAARD DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2021
Last Update Date: 10/17/2025
Certification Date: 10/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10310 THE GROVE BLVD
BATON ROUGE LA
70836-6455
US

IV. Provider business mailing address

10310 THE GROVE BLVD
BATON ROUGE LA
70836-6455
US

V. Phone/Fax

Practice location:
  • Phone: 225-388-6630
  • Fax:
Mailing address:
  • Phone: 225-388-6630
  • Fax: 225-761-5702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number347471
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101028098
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: