Provider Demographics
NPI:1710047865
Name:HANSEN, DAVID JOHN (OD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JOHN
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 1:10120 STONEBRIDGE TR
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-9568
Mailing Address - Country:US
Mailing Address - Phone:651-439-1335
Mailing Address - Fax:
Practice Address - Street 1:406 ROSEDALE CENTER
Practice Address - Street 2:PEARLE VISION
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113
Practice Address - Country:US
Practice Address - Phone:651-631-9394
Practice Address - Fax:651-631-9698
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1889152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
V31418Medicare UPIN