Provider Demographics
NPI:1669474896
Name:HEGSTROM, TODD E (MD)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:E
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 308
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81402-0308
Mailing Address - Country:US
Mailing Address - Phone:970-497-8416
Mailing Address - Fax:970-467-8410
Practice Address - Street 1:2351 G RD
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81505-9641
Practice Address - Country:US
Practice Address - Phone:970-644-3237
Practice Address - Fax:970-644-3259
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.00257452085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO74609858Medicaid
COP00215043Medicare PIN
TXB23400Medicare UPIN
CO801603Medicare ID - Type Unspecified