Provider Demographics
NPI:1073126835
Name:HANSEN, DOUGLAS A JR
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:A
Last Name:HANSEN
Suffix:JR
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 1:1344 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44504-1703
Mailing Address - Country:US
Mailing Address - Phone:330-467-7131
Mailing Address - Fax:
Practice Address - Street 1:1344 5TH AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44504-1703
Practice Address - Country:US
Practice Address - Phone:330-467-7131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-31
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2488400Medicaid