Provider Demographics
NPI:1346417912
Name:HAGAN, MATILDA NANA AMBA (MD)
Entity Type:Individual
Prefix:DR
First Name:MATILDA
Middle Name:NANA AMBA
Last Name:HAGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:301 SAINT PAUL PL
Mailing Address - Street 2:MEDICAL STAFF OFFICE
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21202-2102
Mailing Address - Country:US
Mailing Address - Phone:410-659-2802
Mailing Address - Fax:
Practice Address - Street 1:301 SAINT PAUL PL
Practice Address - Street 2:POB 718
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-2102
Practice Address - Country:US
Practice Address - Phone:410-332-9356
Practice Address - Fax:410-783-5884
Is Sole Proprietor?:No
Enumeration Date:2008-05-13
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0078377207RG0100X, 207R00000X, 207RG0100X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine