Provider Demographics
NPI:1326009465
Name:HAGSTROM, GARRY L (MD)
Entity Type:Individual
Prefix:
First Name:GARRY
Middle Name:L
Last Name:HAGSTROM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4224 TENNYSON ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77005-2752
Mailing Address - Country:US
Mailing Address - Phone:713-667-6124
Mailing Address - Fax:
Practice Address - Street 1:1200 BINZ ST
Practice Address - Street 2:1180
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77004-6900
Practice Address - Country:US
Practice Address - Phone:713-520-6790
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX10014996Medicaid
TX81C091OtherBLUE CROSS BLUE SHEILD
TXB23252Medicare UPIN
TX81C091Medicare ID - Type Unspecified