Provider Demographics
NPI:1184725632
Name:SWAIN, CARLYLE DEREK (OD)
Entity type:Individual
Prefix:DR
First Name:CARLYLE
Middle Name:DEREK
Last Name:SWAIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:PROF
Other - First Name:CARL
Other - Middle Name:
Other - Last Name:SWAIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1107 W 8600 S
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-8432
Mailing Address - Country:US
Mailing Address - Phone:801-860-5100
Mailing Address - Fax:
Practice Address - Street 1:11328 S JORDAN GTWY
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-4112
Practice Address - Country:US
Practice Address - Phone:801-571-1364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT328411-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU62393Medicare UPIN