Provider Demographics
NPI:1922078369
Name:HAGEDORN, DAVID J (DO)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:HAGEDORN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:MR
Other - First Name:DAVID
Other - Middle Name:JAMES
Other - Last Name:HAGEDORN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:P.O. BOX 2880
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50704-2880
Mailing Address - Country:US
Mailing Address - Phone:319-272-2002
Mailing Address - Fax:319-272-2071
Practice Address - Street 1:2101 KIMBALL AVENUE
Practice Address - Street 2:SUITE 401
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50702
Practice Address - Country:US
Practice Address - Phone:319-272-2002
Practice Address - Fax:319-272-2071
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03115207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0725283Medicaid
IAI21674Medicare PIN
IAG60989Medicare UPIN