Provider Demographics
NPI:1538277629
Name:HANSEN, DAVID VICTOR (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:VICTOR
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 1:2935 N 4000 W
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-3159
Mailing Address - Country:US
Mailing Address - Phone:208-356-8581
Mailing Address - Fax:208-356-3066
Practice Address - Street 1:450 E MAIN ST
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2048
Practice Address - Country:US
Practice Address - Phone:208-359-6508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM57092085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY115647-00Medicaid
WY115647-00Medicaid
ID1375264Medicare ID - Type Unspecified
WY308598Medicare ID - Type Unspecified