Provider Demographics
NPI:1295997450
Name:HASENOUR, DERRICK L (MD)
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:L
Last Name:HASENOUR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:14 TRAFALGAR SQ
Mailing Address - Street 2:
Mailing Address - City:TRAFALGAR
Mailing Address - State:IN
Mailing Address - Zip Code:46181-9515
Mailing Address - Country:US
Mailing Address - Phone:317-412-9190
Mailing Address - Fax:317-878-2302
Practice Address - Street 1:55 N MILFORD DR
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:IN
Practice Address - Zip Code:46131-7308
Practice Address - Country:US
Practice Address - Phone:317-739-4848
Practice Address - Fax:317-346-4062
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN11015132A207Q00000X
IN01071061A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201067650Medicaid
INP01105039Medicare PIN
INM400070798Medicare PIN