Provider Demographics
NPI:1770634081
Name:HAGEN, KATHARYN (MD)
Entity Type:Individual
Prefix:
First Name:KATHARYN
Middle Name:
Last Name:HAGEN
Suffix:
Gender:F
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 7001
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91357-7001
Mailing Address - Country:US
Mailing Address - Phone:818-888-7815
Mailing Address - Fax:818-715-1722
Practice Address - Street 1:700 ALAMO PINTADO RD
Practice Address - Street 2:
Practice Address - City:SOLVANG
Practice Address - State:CA
Practice Address - Zip Code:93463-2269
Practice Address - Country:US
Practice Address - Phone:805-686-3965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA49903207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A499030OtherEDS - MEDICAL
CA00A499030OtherEDS - MEDICAL
CAF30622Medicare UPIN