Provider Demographics
NPI:1942213251
Name:SWANSON, MARK (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
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 1:1716 UNIVERSITY BLVD
Mailing Address - Street 2:HPB G080A
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35294-0001
Mailing Address - Country:US
Mailing Address - Phone:205-975-2020
Mailing Address - Fax:205-934-6755
Practice Address - Street 1:1716 UNIVERSITY BLVD
Practice Address - Street 2:HPB G080A
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35294-0001
Practice Address - Country:US
Practice Address - Phone:205-975-2020
Practice Address - Fax:205-934-6755
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS593TA168152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000059978Medicaid
AL51059988OtherBCBS
ALT69085OtherVIVA
AL000059988Medicaid
AL51059978OtherBCBS OF ALABAMA
0279620004Medicare NSC
AL000059988Medicaid
AL410021309Medicare ID - Type UnspecifiedRAILROAD
AL000059978Medicare PIN
AL000059988Medicare PIN
ALT69085OtherVIVA