Provider Demographics
NPI:1609967900
Name:SWAN, KIRTLAND DANA (MD)
Entity Type:Individual
Prefix:
First Name:KIRTLAND
Middle Name:DANA
Last Name:SWAN
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 1:113 SAINT THOMAS ST STE A
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-4575
Mailing Address - Country:US
Mailing Address - Phone:337-235-7561
Mailing Address - Fax:
Practice Address - Street 1:113 SAINT THOMAS ST STE A
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-4575
Practice Address - Country:US
Practice Address - Phone:337-235-7561
Practice Address - Fax:337-237-8666
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA 013847261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA55289Medicare ID - Type Unspecified
LAB65702Medicare UPIN