Provider Demographics
NPI:1407293061
Name:HANEN, JOSHUA JESSIE DEWAR SMITH (JD, OD, FAAO)
Entity Type:Individual
Prefix:DR
First Name:JOSHUA
Middle Name:JESSIE DEWAR SMITH
Last Name:HANEN
Suffix:
Gender:M
Credentials:JD, OD, FAAO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:4323 E LAKE ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406-2307
Mailing Address - Country:US
Mailing Address - Phone:612-722-1003
Mailing Address - Fax:612-721-6336
Practice Address - Street 1:4323 E LAKE ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406-2307
Practice Address - Country:US
Practice Address - Phone:612-722-1003
Practice Address - Fax:612-721-6336
Is Sole Proprietor?:No
Enumeration Date:2013-05-22
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3331152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WS0006X, 152WV0400X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN410003787Medicare PIN