Provider Demographics
NPI:1922083559
Name:HAGEDORN, JOEL S (MD)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:S
Last Name:HAGEDORN
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 1:355 NW RICHMOND BEACH RD
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98177-3101
Mailing Address - Country:US
Mailing Address - Phone:206-546-5181
Mailing Address - Fax:206-546-6575
Practice Address - Street 1:355 NW RICHMOND BEACH RD
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98177-3101
Practice Address - Country:US
Practice Address - Phone:206-546-5181
Practice Address - Fax:206-546-6575
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00026091207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP00312217OtherRAILROAD MEDICARE
WA1053123Medicaid
WA1053123Medicaid
WAE57472Medicare UPIN