Provider Demographics
NPI:1467433557
Name:HAGAN, DAVID JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JOHN
Last Name:HAGAN
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 1:1120 N MELVIN ST
Mailing Address - Street 2:
Mailing Address - City:GIBSON CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60936-1477
Mailing Address - Country:US
Mailing Address - Phone:217-784-8148
Mailing Address - Fax:
Practice Address - Street 1:222 N SANGAMON AVE
Practice Address - Street 2:
Practice Address - City:GIBSON CITY
Practice Address - State:IL
Practice Address - Zip Code:60936-1345
Practice Address - Country:US
Practice Address - Phone:217-784-8148
Practice Address - Fax:217-784-8160
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036066538207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
2715526OtherBCBS
143882OtherRIVERBEND MEDICARE
D15269Medicare UPIN
962290Medicare ID - Type Unspecified