Provider Demographics
NPI:1306823364
Name:HANSEN, ERIC SAMUEL (DO)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:SAMUEL
Last Name:HANSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:532 LAFAYETTE RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SPARTA
Mailing Address - State:NJ
Mailing Address - Zip Code:07871-4411
Mailing Address - Country:US
Mailing Address - Phone:973-940-0423
Mailing Address - Fax:973-940-0399
Practice Address - Street 1:212 ROUTE 94
Practice Address - Street 2:SUITE 1-D
Practice Address - City:VERNON
Practice Address - State:NJ
Practice Address - Zip Code:07462
Practice Address - Country:US
Practice Address - Phone:973-209-2162
Practice Address - Fax:973-209-2665
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB06308800207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7575700Medicaid
NJ009436CL6Medicare PIN
NJG68879Medicare UPIN
NJ009436PXEMedicare PIN