Provider Demographics
NPI:1598735912
Name:SWANSON, THOMAS R (OD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:R
Last Name:SWANSON
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 1:1821 DOUGLAS BLVD
Mailing Address - Street 2:SUITE C4
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-2910
Mailing Address - Country:US
Mailing Address - Phone:916-786-6633
Mailing Address - Fax:916-786-6617
Practice Address - Street 1:1821 DOUGLAS BLVD
Practice Address - Street 2:SUITE C4
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-2910
Practice Address - Country:US
Practice Address - Phone:916-786-6633
Practice Address - Fax:916-786-6617
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA06570TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADE3871OtherRAILROAD MEDICARE
CAP00289444OtherRAILROAD MEDICARE
CASD0065700Medicaid
CAOPT 6570 TPLOtherLICENSE
CASD0065700OtherBLUE SHIELD OF CALIFORNIA
CASD0065700Medicare PIN
CASD0065700OtherBLUE SHIELD OF CALIFORNIA
CAOPT 6570 TPLOtherLICENSE
CAT10357Medicare UPIN
CACJ665ZMedicare PIN