Provider Demographics
NPI:1689663718
Name:HAGAN, TERRY M (MD)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:M
Last Name:HAGAN
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 1:4010 DUPONT CIR STE 202
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4847
Mailing Address - Country:US
Mailing Address - Phone:502-326-3011
Mailing Address - Fax:502-324-4577
Practice Address - Street 1:4010 DUPONT CIR STE 202
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4847
Practice Address - Country:US
Practice Address - Phone:502-326-3011
Practice Address - Fax:502-324-4577
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY215952084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64215957Medicaid
KYR66491Medicare UPIN
KY64215957Medicaid