Provider Demographics
NPI:1871600122
Name:HANSEN, DOUGLAS P (OD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:P
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:PO BOX 1506
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-0409
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9598 MICKELBERRY RD NW
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-8339
Practice Address - Country:US
Practice Address - Phone:360-698-5062
Practice Address - Fax:360-698-5231
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00002055152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR123328Medicaid
WA1021102Medicaid
WA410043367OtherRAIL ROAD MEDICARE
WA410045030OtherRAIL ROAD MEDICARE
WA410021676OtherRAIL ROAD MEDICARE
OR410045029OtherRAIL ROAD MEDICARE
WAG000355061Medicare PIN
U41183Medicare UPIN
WA410045030OtherRAIL ROAD MEDICARE
WAG000165111Medicare PIN
ORR041WFBNKBMedicare PIN
WAG319209216Medicare PIN