Provider Demographics
NPI:1174675268
Name:HANSON, KRISTOPHER MARK (MD)
Entity Type:Individual
Prefix:
First Name:KRISTOPHER
Middle Name:MARK
Last Name:HANSON
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 1:5070 BRADENTON AVE
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-3520
Mailing Address - Country:US
Mailing Address - Phone:614-764-1777
Mailing Address - Fax:614-764-9555
Practice Address - Street 1:5070 BRADENTON AVE
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017-3520
Practice Address - Country:US
Practice Address - Phone:614-764-1777
Practice Address - Fax:614-764-9555
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.091229207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2844444Medicaid
OH2844444Medicaid