Provider Demographics
NPI:1396486320
Name:HAGENS, THEODORE (MD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:HAGENS
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 1:200 JEFFERSON AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4502
Mailing Address - Country:US
Mailing Address - Phone:616-685-6867
Mailing Address - Fax:
Practice Address - Street 1:8700 BEVERLY BLVD # M335
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90048-1804
Practice Address - Country:US
Practice Address - Phone:310-423-3095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43510490442085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology