Provider Demographics
NPI:1386629228
Name:SWENSEN, KRISTA L (OD)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:L
Last Name:SWENSEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45331-1401
Mailing Address - Country:US
Mailing Address - Phone:937-548-6111
Mailing Address - Fax:937-548-0893
Practice Address - Street 1:133 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:OH
Practice Address - Zip Code:45331
Practice Address - Country:US
Practice Address - Phone:937-548-6111
Practice Address - Fax:937-548-0893
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5454T2366152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
2202589OtherUNITED HEALTH CARE
A003OtherTRI CARE FOR LIFE
OH000000365733OtherANTHEM
OH000000365733OtherANTHEM
V05255Medicare UPIN