Provider Demographics
NPI:1255316956
Name:HANSON, MARK ALLEN (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALLEN
Last Name:HANSON
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:PO BOX 220
Mailing Address - Street 2:
Mailing Address - City:BLACK RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54615-0220
Mailing Address - Country:US
Mailing Address - Phone:715-284-3111
Mailing Address - Fax:
Practice Address - Street 1:127 MAIN ST
Practice Address - Street 2:
Practice Address - City:BLACK RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54615-1769
Practice Address - Country:US
Practice Address - Phone:715-284-3111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2876-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI19030Medicaid
WI38626300Medicaid
WIU93450Medicare UPIN
WI19030Medicaid