Provider Demographics
NPI:1295730992
Name:HANSEN, KENNETH RICHARD (OD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:RICHARD
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 1:311 N ANKENY BLVD
Mailing Address - Street 2:
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50023-1711
Mailing Address - Country:US
Mailing Address - Phone:515-964-1671
Mailing Address - Fax:515-964-1714
Practice Address - Street 1:311 N ANKENY BLVD
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-1711
Practice Address - Country:US
Practice Address - Phone:515-964-1671
Practice Address - Fax:515-964-1714
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-17
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01592152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA14296OtherBLUE CROSS BLUE SHIELD
IA1306056510OtherNPI TYPE II
IA1142968Medicaid
IA204163573OtherTAX ID
IA5648350001OtherDMERC
IADE6338OtherRAIL ROAD MEDICARE
IA204163573OtherTAX ID
IA14296OtherBLUE CROSS BLUE SHIELD