Provider Demographics
NPI:1003974411
Name:HAGEN, LARRY A (OD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:A
Last Name:HAGEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 NORTH 6TH ST
Mailing Address - Street 2:
Mailing Address - City:TOMAHAWK
Mailing Address - State:WI
Mailing Address - Zip Code:54487
Mailing Address - Country:US
Mailing Address - Phone:715-453-3636
Mailing Address - Fax:715-453-3011
Practice Address - Street 1:318 NORTH 6TH ST
Practice Address - Street 2:
Practice Address - City:TOMAHAWK
Practice Address - State:WI
Practice Address - Zip Code:54487
Practice Address - Country:US
Practice Address - Phone:715-453-3636
Practice Address - Fax:715-453-3011
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1307152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38567600Medicaid
T62095Medicare UPIN