Provider Demographics
NPI:1538124110
Name:HEGSTROM, JOHN LAWRENCE (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:LAWRENCE
Last Name:HEGSTROM
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:PO BOX 744127
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75374-0968
Mailing Address - Country:US
Mailing Address - Phone:719-776-5816
Mailing Address - Fax:719-776-2108
Practice Address - Street 1:2222 N NEVADA AVENUE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907
Practice Address - Country:US
Practice Address - Phone:719-776-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO23966207ZP0102X
TXG7526207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01239664Medicaid
CO01239664Medicaid
131588Medicare ID - Type Unspecified