Healthcare Provider Details

I. General information

NPI: 1609228089
Provider Name (Legal Business Name): ANTHONY T SWANHOLM OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2016
Last Update Date: 04/19/2021
Certification Date: 04/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 JAMES SIMPSON JR WAY
COVINGTON KY
41011-0801
US

IV. Provider business mailing address

PO BOX 635283
CINCINNATI OH
45263-5286
US

V. Phone/Fax

Practice location:
  • Phone: 859-655-3111
  • Fax: 859-655-3110
Mailing address:
  • Phone: 859-344-5555
  • Fax: 859-344-5554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT.006714
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2057DT
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: