Provider Demographics
NPI:1093745515
Name:HAGEN, EDWARD M (OD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:M
Last Name:HAGEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4 GARDEN CTR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-7026
Mailing Address - Country:US
Mailing Address - Phone:303-469-1941
Mailing Address - Fax:303-469-6634
Practice Address - Street 1:4 GARDEN CTR
Practice Address - Street 2:SUITE 100
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020-7026
Practice Address - Country:US
Practice Address - Phone:303-469-1941
Practice Address - Fax:303-469-6634
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO1356152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T60878Medicare UPIN