Provider Demographics
NPI:1649430026
Name:HAGEN, JOHN GABRIEL (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:GABRIEL
Last Name:HAGEN
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 1:68 S SERVICE RD
Mailing Address - Street 2:SUITE 350
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-2354
Mailing Address - Country:US
Mailing Address - Phone:516-945-3000
Mailing Address - Fax:
Practice Address - Street 1:712 W HURON ST APT 107
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-4261
Practice Address - Country:US
Practice Address - Phone:917-434-3548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301098090207L00000X
390200000X
NYP73032207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03463898Medicaid