Provider Demographics
NPI:1073681128
Name:SHWOM, IRWIN M (OD)
Entity Type:Individual
Prefix:
First Name:IRWIN
Middle Name:M
Last Name:SHWOM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421BROADWAY
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:MA
Mailing Address - Zip Code:02149-3435
Mailing Address - Country:US
Mailing Address - Phone:617-387-1904
Mailing Address - Fax:617-387-2781
Practice Address - Street 1:421BROADWAY
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:MA
Practice Address - Zip Code:02149-3435
Practice Address - Country:US
Practice Address - Phone:617-387-1904
Practice Address - Fax:617-387-2781
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2848152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA152123OtherHARVARD PILGRIM HEALTHCAR
MA0240700001OtherDMERC MEDICARE
MA2200810OtherUNITED HEALTH CARE
MA0006195OtherNEIGHBORHOOD HEALTH PLAN
MA0339598Medicaid
MA81119OtherAETNA
MA708838OtherTUFTS HEALTH PLAN
MA98858501OtherNETWORK HEALTHCARE
MA3526OtherFALLON COMMUNITY HEALTH
MAW15448OtherBC BS OF MASSACHUSETTS
MA410003507OtherRAILROAD MEDICARE
MA98858501OtherNETWORK HEALTHCARE
MA187658Medicare ID - Type Unspecified