Provider Demographics
NPI:1740247014
Name:HAGAN, KENNETH D (M D)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:D
Last Name:HAGAN
Suffix:
Gender:M
Credentials:M D
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Mailing Address - Street 1:11945 SAN JOSE BLVD
Mailing Address - Street 2:BLDG 300
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-1627
Mailing Address - Country:US
Mailing Address - Phone:904-396-1725
Mailing Address - Fax:904-399-1717
Practice Address - Street 1:3627 UNIVERSITY BLVD S
Practice Address - Street 2:SUITE 700
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4230
Practice Address - Country:US
Practice Address - Phone:904-399-5678
Practice Address - Fax:904-399-8488
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2013-06-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME61915208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00062700OtherRAILROAD MEDICARE
FL102532OtherAVMED
FL1717114OtherCIGNA
FL4565405OtherAETNA
FL18738OtherBCBS
FL18738OtherBCBS
FLF55097Medicare UPIN