Provider Demographics
NPI:1679520977
Name:HERMANSEN, DANE KARTSEN (MD)
Entity Type:Individual
Prefix:
First Name:DANE
Middle Name:KARTSEN
Last Name:HERMANSEN
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 1:300 CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-5956
Mailing Address - Country:US
Mailing Address - Phone:386-673-5100
Mailing Address - Fax:386-673-6014
Practice Address - Street 1:300 CLYDE MORRIS BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5956
Practice Address - Country:US
Practice Address - Phone:386-673-5100
Practice Address - Fax:386-673-6014
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0069059208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLB91603Medicare UPIN
FL27578ZMedicare PIN