Provider Demographics
NPI:1821046137
Name:SWANZ, DONALD S (OD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:S
Last Name:SWANZ
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 1:313 W 3RD ST
Mailing Address - Street 2:#102
Mailing Address - City:LA JUNTA
Mailing Address - State:CO
Mailing Address - Zip Code:81050-1411
Mailing Address - Country:US
Mailing Address - Phone:719-384-2582
Mailing Address - Fax:719-384-2582
Practice Address - Street 1:313 W 3RD ST
Practice Address - Street 2:#102
Practice Address - City:LA JUNTA
Practice Address - State:CO
Practice Address - Zip Code:81050-1411
Practice Address - Country:US
Practice Address - Phone:719-384-2582
Practice Address - Fax:719-384-2582
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO883152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08008831Medicaid
CO79013Medicare ID - Type Unspecified
CO08008831Medicaid