Provider Demographics
NPI:1114019056
Name:HAGEN, GEORGE H (OD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:H
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 1:1114 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TRINIDAD
Mailing Address - State:CO
Mailing Address - Zip Code:81082-2034
Mailing Address - Country:US
Mailing Address - Phone:719-846-7342
Mailing Address - Fax:719-846-4041
Practice Address - Street 1:1114 E MAIN ST
Practice Address - Street 2:
Practice Address - City:TRINIDAD
Practice Address - State:CO
Practice Address - Zip Code:81082-2034
Practice Address - Country:US
Practice Address - Phone:719-846-7342
Practice Address - Fax:719-846-4041
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO835152W00000X
332B00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08008351Medicaid
CO3895230001Medicare NSC
CO08008351Medicaid
COT60892Medicare UPIN