Provider Demographics
NPI:1952397499
Name:HAGER, MARK R (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:HAGER
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 1:379 6TH AVE W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34205-8820
Mailing Address - Country:US
Mailing Address - Phone:941-782-4259
Mailing Address - Fax:941-782-4101
Practice Address - Street 1:379 6TH AVE W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34205-8820
Practice Address - Country:US
Practice Address - Phone:941-782-4259
Practice Address - Fax:941-782-4101
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-20
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME788692084P0800X
FL788692084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL265053300Medicaid
H72038Medicare UPIN
FL265053300Medicaid