Provider Demographics
NPI:1063593374
Name:HANSEN, DARRELL ROBERT (MD)
Entity type:Individual
Prefix:
First Name:DARRELL
Middle Name:ROBERT
Last Name:HANSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1213 COFFEE RD
Mailing Address - Street 2:STE A
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-4229
Mailing Address - Country:US
Mailing Address - Phone:209-549-9900
Mailing Address - Fax:
Practice Address - Street 1:1213 COFFEE RD
Practice Address - Street 2:STE A
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-4229
Practice Address - Country:US
Practice Address - Phone:209-549-9900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG27886207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA43532Medicare UPIN