Provider Demographics
NPI:1841272069
Name:HAGAN, BENJAMIN NTI (MD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:NTI
Last Name:HAGAN
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 1:599 SOUTH HAMILTON ROAD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213
Mailing Address - Country:US
Mailing Address - Phone:614-235-9119
Mailing Address - Fax:614-235-9121
Practice Address - Street 1:599 SOUTH HAMILTON ROAD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213
Practice Address - Country:US
Practice Address - Phone:614-235-9119
Practice Address - Fax:614-235-9121
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35081834207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH35081834OtherOHIO STATE LICENSE NO
OH2458693Medicaid
OH2458693Medicaid
OH35081834OtherOHIO STATE LICENSE NO
OHH49854Medicare UPIN
4100492Medicare PIN