Provider Demographics
NPI:1528044385
Name:HANSEN, VINCENT L (MD)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:L
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 1:4403 HARRISON BLVD
Mailing Address - Street 2:#1685
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-3271
Mailing Address - Country:US
Mailing Address - Phone:801-387-7150
Mailing Address - Fax:801-387-7155
Practice Address - Street 1:4403 HARRISON BLVD
Practice Address - Street 2:#1685
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-3271
Practice Address - Country:US
Practice Address - Phone:801-387-7150
Practice Address - Fax:801-387-7155
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1556821205207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT04781Medicaid
UT005536867Medicare ID - Type Unspecified#2
D07274Medicare UPIN
UT005701325Medicare ID - Type Unspecified#3
UT000002356Medicare ID - Type Unspecified