Provider Demographics
NPI:1225178593
Name:HANSON, DOUGLASS EUGENE (OPTOMETRIST)
Entity Type:Individual
Prefix:DR
First Name:DOUGLASS
Middle Name:EUGENE
Last Name:HANSON
Suffix:
Gender:M
Credentials:OPTOMETRIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 E MAIN ST
Mailing Address - Street 2:PO BOX 547
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-1927
Mailing Address - Country:US
Mailing Address - Phone:208-356-0881
Mailing Address - Fax:208-359-9680
Practice Address - Street 1:24 E MAIN ST
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1927
Practice Address - Country:US
Practice Address - Phone:208-356-0881
Practice Address - Fax:208-359-9680
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP 0703152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
20000234Medicare PIN