Provider Demographics
NPI:1720146277
Name:DR P O SWANSON OD PC
Entity Type:Organization
Organization Name:DR P O SWANSON OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BLEW
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:641-684-4695
Mailing Address - Street 1:333 CHURCH
Mailing Address - Street 2:
Mailing Address - City:OTTUMWA
Mailing Address - State:IA
Mailing Address - Zip Code:52501
Mailing Address - Country:US
Mailing Address - Phone:641-684-4695
Mailing Address - Fax:641-684-7201
Practice Address - Street 1:333 CHURCH
Practice Address - Street 2:
Practice Address - City:OTTUMWA
Practice Address - State:IA
Practice Address - Zip Code:52501
Practice Address - Country:US
Practice Address - Phone:641-684-4695
Practice Address - Fax:641-684-7201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2009-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1734152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0212365Medicaid
21236Medicare PIN
T01203Medicare UPIN
IA0212365Medicaid
IA21236001Medicare PIN