Provider Demographics
NPI:1750693628
Name:HAGGE, MARYHELEN (MD)
Entity type:Individual
Prefix:DR
First Name:MARYHELEN
Middle Name:
Last Name:HAGGE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1621 S CARSON AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74119-4215
Mailing Address - Country:US
Mailing Address - Phone:918-592-1989
Mailing Address - Fax:918-592-1877
Practice Address - Street 1:104 E BRYAN 74066
Practice Address - Street 2:
Practice Address - City:SALPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066
Practice Address - Country:US
Practice Address - Phone:918-224-4280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2010-07-08
Deactivation Date:2010-04-23
Deactivation Code:
Reactivation Date:2010-07-08
Provider Licenses
StateLicense IDTaxonomies
OK18583207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100174450AMedicaid
OK100174450DMedicaid
OK100174450DMedicaid
OK100174450AMedicaid