Provider Demographics
NPI:1215137963
Name:JERRY A. HANSON, M.D. A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:JERRY A. HANSON, M.D. A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:HANSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:048-295-2257
Mailing Address - Street 1:2030 FOREST AVE
Mailing Address - Street 2:STE. 210
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-4833
Mailing Address - Country:US
Mailing Address - Phone:408-295-2257
Mailing Address - Fax:408-295-2264
Practice Address - Street 1:2030 FOREST AVE
Practice Address - Street 2:STE. 210
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-4833
Practice Address - Country:US
Practice Address - Phone:408-295-2257
Practice Address - Fax:408-295-2264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-20
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC33389261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ05336ZMedicare PIN
CAA35253Medicare UPIN