Provider Demographics
NPI:1720209380
Name:HAGEMEYER, MATTHEW A (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:A
Last Name:HAGEMEYER
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 5546
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-5546
Mailing Address - Country:US
Mailing Address - Phone:801-475-3700
Mailing Address - Fax:801-475-3701
Practice Address - Street 1:698 12TH ST
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84404-6200
Practice Address - Country:US
Practice Address - Phone:801-475-3700
Practice Address - Fax:801-475-3701
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9405644-1205207Q00000X
WY8826A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU000091534Medicare PIN