Provider Demographics
NPI:1619947801
Name:HAGSTROM, ALAN KYLE (MD)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:KYLE
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 1:250 PARK SHORE DR APT 202
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34103-3440
Mailing Address - Country:US
Mailing Address - Phone:239-404-3379
Mailing Address - Fax:
Practice Address - Street 1:1415 PANTHER LN
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109-7874
Practice Address - Country:US
Practice Address - Phone:239-404-3379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ23903207L00000X
FLME114651208VP0000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ436601Medicaid
F95259Medicare UPIN
AZ05WCHKJ52Medicare ID - Type Unspecified