Provider Demographics
NPI:1134122880
Name:HAGAN, JAMES M (DPM)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:M
Last Name:HAGAN
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 1:175 PARK ST
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-4803
Mailing Address - Country:US
Mailing Address - Phone:707-263-9595
Mailing Address - Fax:707-263-5576
Practice Address - Street 1:175 PARK ST
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-4803
Practice Address - Country:US
Practice Address - Phone:707-263-9595
Practice Address - Fax:707-263-5576
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE1538213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA480028898OtherRAILROAD MEDICARE
CAZZZ17250ZMedicare ID - Type Unspecified
CA000E15380Medicare PIN
CA480028898OtherRAILROAD MEDICARE
CAT10993Medicare UPIN