Provider Demographics
NPI:1578691465
Name:HAGBERG, DONNA JOAN (MD)
Entity Type:Individual
Prefix:DR
First Name:DONNA
Middle Name:JOAN
Last Name:HAGBERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 RIVER RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:COS COB
Mailing Address - State:CT
Mailing Address - Zip Code:06807-2152
Mailing Address - Country:US
Mailing Address - Phone:203-742-1150
Mailing Address - Fax:203-489-3411
Practice Address - Street 1:31 RIVER RD
Practice Address - Street 2:SUITE 102
Practice Address - City:COS COB
Practice Address - State:CT
Practice Address - Zip Code:06807-2152
Practice Address - Country:US
Practice Address - Phone:203-742-1150
Practice Address - Fax:203-489-3411
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010032695CT05OtherANTHEM BLUE CROSS CT NUMB
CT160002273Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
CTF52768Medicare UPIN