Provider Demographics
NPI:1093792723
Name:HAGEN, JEFFREY LARS (DPM)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:LARS
Last Name:HAGEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 W HILLSDALE AVE
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-8222
Mailing Address - Country:US
Mailing Address - Phone:559-738-7500
Mailing Address - Fax:559-734-2055
Practice Address - Street 1:5400 W HILLSDALE AVE
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-8222
Practice Address - Country:US
Practice Address - Phone:559-738-7500
Practice Address - Fax:559-734-2055
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4634213ES0103X, 213E00000X
WAPO807213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1366570772Medicaid
CA1366570772OtherGROUP NPI
CA0217680001Medicare NSC
CACA188299Medicare PIN
CA1366570772Medicaid