Provider Demographics
NPI:1356331938
Name:SWAN, ELISABETH SARAH (OD)
Entity Type:Individual
Prefix:
First Name:ELISABETH
Middle Name:SARAH
Last Name:SWAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4335 HAZEL AVE
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-6669
Mailing Address - Country:US
Mailing Address - Phone:916-966-6080
Mailing Address - Fax:916-966-6919
Practice Address - Street 1:4335 HAZEL AVE
Practice Address - Street 2:
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-6669
Practice Address - Country:US
Practice Address - Phone:916-966-6080
Practice Address - Fax:916-966-6919
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9676T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0096760OtherMEDI-CAL
CAU41053Medicare UPIN
CASD0096760OtherMEDI-CAL
CADN432ZMedicare PIN