Provider Demographics
NPI:1790793495
Name:DEHAVEN, HANK D (OD)
Entity Type:Individual
Prefix:DR
First Name:HANK
Middle Name:D
Last Name:DEHAVEN
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 1:122 HIGHWAY 76
Mailing Address - Street 2:
Mailing Address - City:WHITE HOUSE
Mailing Address - State:TN
Mailing Address - Zip Code:37188-9291
Mailing Address - Country:US
Mailing Address - Phone:615-672-6896
Mailing Address - Fax:615-672-6783
Practice Address - Street 1:122 HIGHWAY 76
Practice Address - Street 2:
Practice Address - City:WHITE HOUSE
Practice Address - State:TN
Practice Address - Zip Code:37188-9291
Practice Address - Country:US
Practice Address - Phone:615-672-6896
Practice Address - Fax:615-672-6783
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2277152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN6537319OtherCIGNA
TN3945747Medicaid
TN4108253OtherBLUE CROSS BLUE SHIELD TN
TNU86216Medicare UPIN
TN3945747Medicare ID - Type Unspecified