Provider Demographics
NPI:1811967706
Name:SWANSON, SOPHIA NMI (OD)
Entity type:Individual
Prefix:DR
First Name:SOPHIA
Middle Name:NMI
Last Name:SWANSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:SOPHIA
Other - Middle Name:NMI
Other - Last Name:SWEDBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:14335 75TH ST NE
Mailing Address - Street 2:
Mailing Address - City:HOOPLE
Mailing Address - State:ND
Mailing Address - Zip Code:58243-9444
Mailing Address - Country:US
Mailing Address - Phone:701-894-6205
Mailing Address - Fax:
Practice Address - Street 1:2800 S COLUMBIA RD
Practice Address - Street 2:J.C. PENNEY OPTICAL-COLUMBIA MALL
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-6076
Practice Address - Country:US
Practice Address - Phone:701-746-4810
Practice Address - Fax:701-746-9260
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-24
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND576152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND60525Medicaid
ND60525Medicaid
ND711747Medicare ID - Type Unspecified