Provider Demographics
NPI:1215923842
Name:HANSEN, MARK (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
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 1:555 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:ESTES PARK
Mailing Address - State:CO
Mailing Address - Zip Code:80517-6312
Mailing Address - Country:US
Mailing Address - Phone:970-586-2317
Mailing Address - Fax:970-577-4338
Practice Address - Street 1:555 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:ESTES PARK
Practice Address - State:CO
Practice Address - Zip Code:80517-6312
Practice Address - Country:US
Practice Address - Phone:970-586-2200
Practice Address - Fax:970-577-4338
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-20
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO346832085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01346832Medicaid
F48267Medicare UPIN
CO38591Medicare ID - Type Unspecified