Provider Demographics
NPI:1669799664
Name:HAGSTROM, MINDY MARIE (OD)
Entity type:Individual
Prefix:DR
First Name:MINDY
Middle Name:MARIE
Last Name:HAGSTROM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:MINDY
Other - Middle Name:MARIE
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:3635 E INVERNESS AVE
Mailing Address - Street 2:STE 105
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-3848
Mailing Address - Country:US
Mailing Address - Phone:480-345-7520
Mailing Address - Fax:480-844-8633
Practice Address - Street 1:6555 E SOUTHERN AVE STE 1508
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-3724
Practice Address - Country:US
Practice Address - Phone:809-643-5424
Practice Address - Fax:480-240-9120
Is Sole Proprietor?:No
Enumeration Date:2010-04-29
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1720152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist