Provider Demographics
NPI:1760512461
Name:HAGADORN, BRUCE A (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:A
Last Name:HAGADORN
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 1:16300 SAND CANYON AVE
Mailing Address - Street 2:805
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-3711
Mailing Address - Country:US
Mailing Address - Phone:949-753-0601
Mailing Address - Fax:
Practice Address - Street 1:16300 SAND CANYON AVE
Practice Address - Street 2:805
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3711
Practice Address - Country:US
Practice Address - Phone:949-753-0601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2010-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG71549174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WG71549AMedicare PIN
F71396Medicare UPIN