Provider Demographics
NPI:1942217161
Name:SWAN, EDGAR EARL (OPTICIAN)
Entity Type:Individual
Prefix:MR
First Name:EDGAR
Middle Name:EARL
Last Name:SWAN
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GALLATIN
Mailing Address - State:TN
Mailing Address - Zip Code:37066-2717
Mailing Address - Country:US
Mailing Address - Phone:615-452-2111
Mailing Address - Fax:615-452-2251
Practice Address - Street 1:137 W BROADWAY
Practice Address - Street 2:
Practice Address - City:GALLATIN
Practice Address - State:TN
Practice Address - Zip Code:37066-2717
Practice Address - Country:US
Practice Address - Phone:615-452-2111
Practice Address - Fax:615-452-2251
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDPO0000000657156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN43794Medicaid
TN0498350001Medicare ID - Type Unspecified