Provider Demographics
NPI:1215984638
Name:HAGEN, ROBERT W (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:HAGEN
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 1:1593 E POLSTON AVE
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-5326
Mailing Address - Country:US
Mailing Address - Phone:208-262-2300
Mailing Address - Fax:208-262-2390
Practice Address - Street 1:315 W DALTON AVE STE B
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-8600
Practice Address - Country:US
Practice Address - Phone:208-209-2066
Practice Address - Fax:208-209-2076
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-8519207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE25091Medicare UPIN
CA00G608810Medicare PIN