Provider Demographics
NPI:1467787226
Name:HANSEN, MARK SPENCER (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:SPENCER
Last Name:HANSEN
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 1:9801 DUPONT AVE S
Mailing Address - Street 2:425
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55431-3100
Mailing Address - Country:US
Mailing Address - Phone:952-888-5800
Mailing Address - Fax:
Practice Address - Street 1:9801 DUPONT AVE S
Practice Address - Street 2:425
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-3100
Practice Address - Country:US
Practice Address - Phone:952-888-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-13
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC2013-00778207W00000X
MN57762207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program