Healthcare Provider Details

I. General information

NPI: 1295997450
Provider Name (Legal Business Name): DERRICK L. HASENOUR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2008
Last Update Date: 10/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 N MILFORD DR
FRANKLIN IN
46131-7308
US

IV. Provider business mailing address

14 TRAFALGAR SQ
TRAFALGAR IN
46181-9515
US

V. Phone/Fax

Practice location:
  • Phone: 317-739-4848
  • Fax: 317-346-4062
Mailing address:
  • Phone: 317-412-9190
  • Fax: 317-878-2302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11015132A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01071061A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: