1598735912 NPI number — THOMAS R SWANSON OD

Table of content: THOMAS R SWANSON OD (NPI 1598735912)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598735912 NPI number — THOMAS R SWANSON OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SWANSON
Provider First Name:
THOMAS
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598735912
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/07/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1821 DOUGLAS BLVD
Provider Second Line Business Mailing Address:
SUITE C4
Provider Business Mailing Address City Name:
ROSEVILLE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95661-2910
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-786-6633
Provider Business Mailing Address Fax Number:
916-786-6617

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1821 DOUGLAS BLVD
Provider Second Line Business Practice Location Address:
SUITE C4
Provider Business Practice Location Address City Name:
ROSEVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95661-2910
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-786-6633
Provider Business Practice Location Address Fax Number:
916-786-6617
Provider Enumeration Date:
01/26/2006

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: 152W00000X , with the licence number:  06570TPL , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DE3871 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: P00289444 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: SD0065700 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: OPT 6570 TPL . This is a "LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: SD0065700 . This is a "BLUE SHIELD OF CALIFORNIA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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