Provider Demographics
NPI:1972522522
Name:HANSEN, III, RAYMOND D (MD)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:D
Last Name:HANSEN, III
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 1:1972 BAYSHORE BLVD
Mailing Address - Street 2:
Mailing Address - City:DUNEDIN
Mailing Address - State:FL
Mailing Address - Zip Code:34698-2577
Mailing Address - Country:US
Mailing Address - Phone:727-736-2513
Mailing Address - Fax:727-734-4701
Practice Address - Street 1:1972 BAYSHORE BLVD
Practice Address - Street 2:
Practice Address - City:DUNEDIN
Practice Address - State:FL
Practice Address - Zip Code:34698-2577
Practice Address - Country:US
Practice Address - Phone:727-736-2513
Practice Address - Fax:727-734-4701
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL80711207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL052445000Medicaid
FL052445000Medicaid
FLK1927Medicare ID - Type Unspecified