Provider Demographics
NPI:1386665016
Name:SWAN, MARK EDWARD (OD MED)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
Last Name:SWAN
Suffix:
Gender:M
Credentials:OD MED
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:
Other - Last Name:SWAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD MED
Mailing Address - Street 1:1124 S STATE ST
Mailing Address - Street 2:MICHIGAN COLLEGE OF OPTOMETRY
Mailing Address - City:BIG RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49307-2256
Mailing Address - Country:US
Mailing Address - Phone:231-591-2222
Mailing Address - Fax:231-591-3991
Practice Address - Street 1:1124 S STATE ST
Practice Address - Street 2:MICHIGAN COLLEGE OF OPTOMETRY
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307-2256
Practice Address - Country:US
Practice Address - Phone:231-591-2222
Practice Address - Fax:231-591-3991
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003186152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM5003186OtherBLUE CROSS
MI4401840Medicaid
MI999998001OtherUSP
MI900006367OtherPRIORITY HEALTH
MI900006367OtherPRIORITY HEALTH
MIE47602037Medicare PIN
U13534Medicare UPIN