Healthcare Provider Details

I. General information

NPI: 1780655621
Provider Name (Legal Business Name): JOHN C HANSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 02/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 CHILDRENS WAY #112
SAN DIEGO CA
92123
US

IV. Provider business mailing address

3860 CALLE FORTUNADA STE 200
SAN DIEGO CA
92123
US

V. Phone/Fax

Practice location:
  • Phone: 858-495-0500
  • Fax: 858-560-4279
Mailing address:
  • Phone: 858-636-4300
  • Fax: 858-636-4319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG68382
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: