Provider Demographics
NPI:1316159940
Name:HANSEN, KENNETH DAVID (OD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:DAVID
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 1:3705 SE 48TH ST
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34480-7385
Mailing Address - Country:US
Mailing Address - Phone:352-622-3711
Mailing Address - Fax:
Practice Address - Street 1:15936 E HIGHWAY 40
Practice Address - Street 2:
Practice Address - City:SILVER SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34488-5144
Practice Address - Country:US
Practice Address - Phone:352-625-0135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 1542152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL19145Medicare ID - Type Unspecified