Provider Demographics
NPI:1750319455
Name:HAGSTROM, MARK R (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:HAGSTROM
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Gender:M
Credentials:MD
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Mailing Address - Street 1:3366 OAKDALE AVE N
Mailing Address - Street 2:SUITE 315
Mailing Address - City:ROBBINSDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55422-2948
Mailing Address - Country:US
Mailing Address - Phone:763-520-7900
Mailing Address - Fax:763-520-7989
Practice Address - Street 1:3366 OAKDALE AVE N
Practice Address - Street 2:SUITE 315
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-2948
Practice Address - Country:US
Practice Address - Phone:763-520-7900
Practice Address - Fax:763-520-7989
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
MN31668207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNF25435Medicare UPIN