Provider Demographics
NPI:1841290996
Name:HANSEN, ROGER VIKE (DO PHD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:VIKE
Last Name:HANSEN
Suffix:
Gender:M
Credentials:DO PHD
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 1475
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50306-1475
Mailing Address - Country:US
Mailing Address - Phone:515-643-4973
Mailing Address - Fax:515-643-2784
Practice Address - Street 1:319 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PANORA
Practice Address - State:IA
Practice Address - Zip Code:50216-1064
Practice Address - Country:US
Practice Address - Phone:641-755-2121
Practice Address - Fax:641-755-2314
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA3182207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0634816Medicaid
IA30652OtherWELLMARK BLUE SHIELD
G85698Medicare UPIN
IAI20465Medicare PIN