Provider Demographics
NPI:1417028952
Name:HANSEN, TERRY MILO (OD)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:MILO
Last Name:HANSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2828 WEST 4700 SOUTH
Mailing Address - Street 2:SUITE D
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84118
Mailing Address - Country:US
Mailing Address - Phone:801-966-6201
Mailing Address - Fax:801-966-6609
Practice Address - Street 1:2828 WEST 4700 SOUTH
Practice Address - Street 2:SUITE D
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84118
Practice Address - Country:US
Practice Address - Phone:801-966-6201
Practice Address - Fax:801-966-6609
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1040152W00000X
UT109507-9934152W00000X
UT109507-8908152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT519520390009Medicaid
UT519520390009Medicaid