Provider Demographics
NPI:1164406211
Name:HANSEN, BRET R (MD)
Entity Type:Individual
Prefix:
First Name:BRET
Middle Name:R
Last Name:HANSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 NW MERCY DR STE 340
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-2348
Mailing Address - Country:US
Mailing Address - Phone:541-677-4319
Mailing Address - Fax:541-644-2294
Practice Address - Street 1:2801 NW MERCY DR
Practice Address - Street 2:SUITE 330
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-2348
Practice Address - Country:US
Practice Address - Phone:541-677-3600
Practice Address - Fax:541-677-3601
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23507208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR286867Medicaid
H63260Medicare UPIN
ORR113132Medicare PIN