Provider Demographics
NPI:1013018100
Name:HANSEN, THEODORE LESTER (OD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:LESTER
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 1:115 EAST LAKE ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408
Mailing Address - Country:US
Mailing Address - Phone:612-827-3857
Mailing Address - Fax:612-827-7204
Practice Address - Street 1:115 EAST LAKE ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408
Practice Address - Country:US
Practice Address - Phone:612-827-3857
Practice Address - Fax:612-827-7204
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2086152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN85750HAOtherBLUE CROSS BLUE SHIELD
MN922371040939OtherPREFERRED ONE
MN2213318OtherMEDICA
MN102434OtherUCARE
MN102434OtherUCARE