Provider Demographics
NPI:1295231017
Name:HAGEN, MATTHEW (DO)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:HAGEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 FISHER ST
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39534-2508
Mailing Address - Country:US
Mailing Address - Phone:228-376-2550
Mailing Address - Fax:228-376-0103
Practice Address - Street 1:301 FISHER ST
Practice Address - Street 2:KEESLER AFB
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39534
Practice Address - Country:US
Practice Address - Phone:228-376-0576
Practice Address - Fax:228-376-0103
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-02
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS30536207R00000X, 208M00000X, 207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program