Provider Demographics
NPI:1649242041
Name:HAGEN, GARY ALAN (OD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:ALAN
Last Name:HAGEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4203 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90814-2922
Mailing Address - Country:US
Mailing Address - Phone:562-433-1700
Mailing Address - Fax:562-433-9945
Practice Address - Street 1:4203 E 4TH ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90814-2922
Practice Address - Country:US
Practice Address - Phone:562-433-1700
Practice Address - Fax:562-433-9945
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6040T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist