Healthcare Provider Details

I. General information

NPI: 1841290996
Provider Name (Legal Business Name): ROGER VIKE HANSEN DO PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 09/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 E MAIN ST
PANORA IA
50216-1064
US

IV. Provider business mailing address

PO BOX 1475
DES MOINES IA
50306-1475
US

V. Phone/Fax

Practice location:
  • Phone: 641-755-2121
  • Fax: 641-755-2314
Mailing address:
  • Phone: 515-643-4973
  • Fax: 515-643-2784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3182
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number3182
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: