Provider Demographics
NPI:1861450868
Name:HAGAN, CHARLOTTE (MD)
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:
Last Name:HAGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CHARLOTTE
Other - Middle Name:
Other - Last Name:NGANELE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4461 STARKEY RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-0620
Mailing Address - Country:US
Mailing Address - Phone:540-345-4946
Mailing Address - Fax:540-982-7164
Practice Address - Street 1:4461 STARKEY RD
Practice Address - Street 2:SUITE 201
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-0620
Practice Address - Country:US
Practice Address - Phone:540-345-4946
Practice Address - Fax:540-982-7164
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012372382084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
1861450868OtherMEDICARE
VVB267BOtherMEDICARE PTAN