Basic Information
| Provider Information | |||||||||
| NPI: | 1194089581 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HANSEN | ||||||||
| FirstName: | DEREK | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1324 LAKELAND HILLS BLVD. | ||||||||
| Address2: | ATTN: MANAGED CARE DEPT. | ||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33805 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2500 N STATE ST | ||||||||
| Address2: | DEPARMENT OF MEDICINE | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019845601 | ||||||||
| FaxNumber: | 6019846665 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2012 | ||||||||
| LastUpdateDate: | 07/02/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 856-L | MS | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0200X | ME135265 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 856-L | 01 | MS | TEMPORARY STATE MEDICAL LICENSE | OTHER |