Provider Demographics
NPI:1689639023
Name:SWIECICKI, MIRA B (OD)
Entity Type:Individual
Prefix:DR
First Name:MIRA
Middle Name:B
Last Name:SWIECICKI
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 1:201 S 19TH ST
Mailing Address - Street 2:
Mailing Address - City:LYNDEN
Mailing Address - State:WA
Mailing Address - Zip Code:98264-1725
Mailing Address - Country:US
Mailing Address - Phone:360-354-2222
Mailing Address - Fax:360-354-0737
Practice Address - Street 1:201 S 19TH ST
Practice Address - Street 2:
Practice Address - City:LYNDEN
Practice Address - State:WA
Practice Address - Zip Code:98264-1725
Practice Address - Country:US
Practice Address - Phone:360-354-2222
Practice Address - Fax:360-354-0737
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3271TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6524SWOtherREGENCE BLUE SHIELD
WA0108450OtherLABOR & INDUSTRIES
WAP00190648OtherRAILROAD MEDICARE-PALMETT
WA2019891Medicaid
WAG8851040OtherMEDICARE ID-PIN
WA6524SWOtherREGENCE BLUE SHIELD
WAG8851040Medicare PIN