Provider Demographics
NPI:1306943972
Name:HANSETER, THOMAS BRIAN (OD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:BRIAN
Last Name:HANSETER
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 1:445 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:WI
Mailing Address - Zip Code:54165-1433
Mailing Address - Country:US
Mailing Address - Phone:920-833-9613
Mailing Address - Fax:
Practice Address - Street 1:303 BAY PARK SQ
Practice Address - Street 2:SPACE 976
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5104
Practice Address - Country:US
Practice Address - Phone:920-497-8399
Practice Address - Fax:920-497-7894
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2302-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIU34863Medicare UPIN