Provider Demographics
NPI:1174100663
Name:SWANSON, DEREK
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:SWANSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 CIVIC CENTER BOULEVARD
Mailing Address - Street 2:4 SOUTH PAVILION, PCAM
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104
Mailing Address - Country:US
Mailing Address - Phone:215-900-3506
Mailing Address - Fax:
Practice Address - Street 1:3400 CIVIC CENTER BOULEVARD
Practice Address - Street 2:4 SOUTH PAVILION, DEPARTMENT OF ORAL AND MAXILLOFACIAL
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:215-900-3506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-29
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program