Provider Demographics
NPI:1568624542
Name:HANZLIK, SHANE R (MD)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:R
Last Name:HANZLIK
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 1:1508 DIVISION ST SUITE 105
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-1584
Mailing Address - Country:US
Mailing Address - Phone:503-905-4104
Mailing Address - Fax:503-656-9464
Practice Address - Street 1:1508 DIVISION ST SUITE 105
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-1584
Practice Address - Country:US
Practice Address - Phone:503-905-4104
Practice Address - Fax:503-656-9464
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD170616207XX0005X, 207X00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program