Provider Demographics
NPI:1255499158
Name:SWANSON, GARY (MD)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:
Last Name:SWANSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 LAS POSAS RD
Mailing Address - Street 2:#100
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-1501
Mailing Address - Country:US
Mailing Address - Phone:805-484-0479
Mailing Address - Fax:
Practice Address - Street 1:3901 LAS POSAS RD
Practice Address - Street 2:#100
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-1501
Practice Address - Country:US
Practice Address - Phone:805-484-0479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG27896207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G278960Medicaid
CAA43536Medicare UPIN
CA00G278960Medicaid