Provider Demographics
NPI:1992034045
Name:SWANN, FRED R (OD)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:R
Last Name:SWANN
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 1:809 N 12TH ST
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:KY
Mailing Address - Zip Code:42071-1648
Mailing Address - Country:US
Mailing Address - Phone:270-753-4101
Mailing Address - Fax:
Practice Address - Street 1:809 N 12TH ST
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:KY
Practice Address - Zip Code:42071-1648
Practice Address - Country:US
Practice Address - Phone:270-753-4101
Practice Address - Fax:270-753-7467
Is Sole Proprietor?:No
Enumeration Date:2009-12-21
Last Update Date:2009-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0985DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist