Provider Demographics
NPI:1972534279
Name:SWENSON, LORI R (MD)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:R
Last Name:SWENSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3336 S 4155 W STE 306
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84120-2045
Mailing Address - Country:US
Mailing Address - Phone:801-964-3855
Mailing Address - Fax:801-964-3860
Practice Address - Street 1:3336 S 4155 W STE 306
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-2045
Practice Address - Country:US
Practice Address - Phone:801-964-3855
Practice Address - Fax:801-964-3860
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT58645451205208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
H54668Medicare UPIN