Provider Demographics
NPI:1710965488
Name:HAGEN, JEFF E (MD)
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:E
Last Name:HAGEN
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 1:301 HIGHWAY 71 W
Mailing Address - Street 2:SUITE 111
Mailing Address - City:BASTROP
Mailing Address - State:TX
Mailing Address - Zip Code:78602-4105
Mailing Address - Country:US
Mailing Address - Phone:512-304-0318
Mailing Address - Fax:512-308-9649
Practice Address - Street 1:301 HIGHWAY 71 W
Practice Address - Street 2:SUITE 111
Practice Address - City:BASTROP
Practice Address - State:TX
Practice Address - Zip Code:78602-4105
Practice Address - Country:US
Practice Address - Phone:512-304-0318
Practice Address - Fax:512-308-9649
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-04
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG3424174400000X
TXG2434207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX041869104Medicaid
TX610342Medicare Oscar/Certification
TXC16434Medicare UPIN