Provider Demographics
NPI:1003804667
Name:HANSEN, ROCKY G (OD)
Entity Type:Individual
Prefix:DR
First Name:ROCKY
Middle Name:G
Last Name:HANSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 S FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48838-1759
Mailing Address - Country:US
Mailing Address - Phone:616-754-7143
Mailing Address - Fax:616-754-2778
Practice Address - Street 1:307 S FRANKLIN
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838-1905
Practice Address - Country:US
Practice Address - Phone:616-754-7143
Practice Address - Fax:616-754-2778
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002646152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIRH002646OtherBLUE CROSS BLUE SHIELD
MI01256OtherPRIORITY HEALTH
MI943153415Medicaid
MIP13290008Medicare PIN
MI01256OtherPRIORITY HEALTH
MIT33291Medicare UPIN
MI943153415Medicaid
MIOP13290Medicare PIN
MIM02720002Medicare PIN