Provider Demographics
NPI:1386785426
Name:HANSEN, MICHAEL R (DPM)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:R
Last Name:HANSEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1956 41ST AVE STE C
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-2561
Mailing Address - Country:US
Mailing Address - Phone:772-567-3338
Mailing Address - Fax:772-567-6397
Practice Address - Street 1:1956 41ST AVE STE C
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-2561
Practice Address - Country:US
Practice Address - Phone:772-567-3338
Practice Address - Fax:772-567-6397
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO0002819213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL65660OtherBCBS FL PROVIDER NUMBER
FLU78845Medicare UPIN
FL65660OtherBCBS FL PROVIDER NUMBER