Provider Demographics
NPI:1770562506
Name:HANSEN, ERIC RODNEY (DO)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:RODNEY
Last Name:HANSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14575 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-3322
Mailing Address - Country:US
Mailing Address - Phone:760-947-0727
Mailing Address - Fax:760-947-6219
Practice Address - Street 1:14575 MAIN ST
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-3322
Practice Address - Country:US
Practice Address - Phone:760-947-0727
Practice Address - Fax:760-947-6219
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8138207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX81380Medicaid
P00153466OtherRAILROAD MEDICARE
O2OA81381Medicare PIN
CA00AX81380Medicaid