Provider Demographics
NPI:1851302855
Name:HANSEN, DWIGHT (OD)
Entity Type:Individual
Prefix:DR
First Name:DWIGHT
Middle Name:
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 1:225 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-1351
Mailing Address - Country:US
Mailing Address - Phone:208-745-8773
Mailing Address - Fax:
Practice Address - Street 1:225 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RIGBY
Practice Address - State:ID
Practice Address - Zip Code:83442-1351
Practice Address - Country:US
Practice Address - Phone:208-745-8773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-747152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002382900Medicaid
ID410015645OtherRR MEDICARE
ID410015645OtherRR MEDICARE
ID1591875Medicare ID - Type Unspecified
ID002382900Medicaid
ID0749560001Medicare NSC